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

We decided that the Plan does not have to waive the cost shares for the medical services provided on January 24, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you have met your obligations for the services rendered. The Plan denied your request. The Plan says the claim processed correctly according to the benefit plan. 
 
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 $1000 deductible.  
 
The file shows that you received a hemorrhoidectomy on the date of service at issue. You have been asked to pay $665.89 for the services. The service you asked the Plan to waive the cost shares for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible. This cost sharing is a contractual obligation that had not been met at the time the services provided was received on January 24, 2020. Therefore, we decided that the Plan does not have to waive the cost shares for the medical services provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 23, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that your provider performed service in good faith. The Plan denied your request. The Plan says the denial of payment for this service 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 March 23, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on February 3, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you disagree with the 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 a $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $300 copayment for an EGD. An EGD 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 an EGD provided on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #23. 
 
You asked the Plan to pre-approve the crown. You say that a full coverage restoration is necessary to restore 
tooth #23 to optimum strength and functioning. The Plan denied your request. The Plan says the claim and x-
ray were not received timely. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation submitted does not show 
that there is significant breakdown of the coronal structure of tooth #23 from caries or fracture to warrant a 
crown restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #23.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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. Our 
physician reviewer found the enrollee is being managed for possible small bowel obstruction since August 1, 
2020. The enrollee is medically stable. The initial treating surgeon has recommended exploratory laparotomy. 
The requested services can be provided in the initial treating facility and does not require transfer to a different 
facility. Therefore, the enrollee does not meet criteria for the requested transfer. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on February 18, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on February 18, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 25, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says there is no valid 
referral for 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 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 September 25, 
2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services provided 
from January 20, 2020 to February 27, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient rehabilitation services. You say that you disagree 
with the charges because you feel that the services were not adequate enough to warrant the 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 40% 
coinsurance for out-of-network outpatient rehabilitation services.  
 
You received outpatient rehabilitation services from an out-of-network provider from January 20, 2020 to 
February 27, 2020. The total allowed amount is $449.78 and 40% of that is $179.91.  
 
You have been asked to pay the total coinsurance amount of $179.91 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall 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 coinsurance for outpatient rehabilitation services provided from January 20, 2020 to 
February 27, 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 February 20, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you saw this provider because 
your primary care provider was no longer available for services. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 50% of 
the total allowed amount for each Medicare-covered out-of-network primary care provider office visit.  
 
You have been asked to pay $53.20 which is 50% of the allowed amount for the office visit. The allowed 
amount is $106.40. ($106.40 x 50% = $53.20). The office visit falls within the Physician/Practitioner services, 
including doctor's office visits benefit category. The record shows the provider is out-of-network. 
 
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 February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power mobility device (scooter). 
 
You asked the Plan to pre-approve power mobility device (scooter). You say that you cannot walk and you 
have no left hip. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of power mobility device (scooter) have not been met. Your provider 
needs to document that you have a mobility limitation that significantly impairs your ability to participate in 
one or more mobility related activities, the mobility limitation cannot be sufficiently and safely resolved by use 
of an appropriately fitted cane or walker. Also, documentation must be submitted by the supplying vendor to 
include home evaluation to determine if home provides adequate access between rooms and that the member is 
able to safely use power operated vehicle (scooter). These criteria are not met because the documentation 
submitted does not include a medical assessment of your physical capability of manage requested device or any 
evaluation indicating the living space can accommodate the device. Therefore, we decided that the Plan does 
not have to pre-approve power mobility device (scooter).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on 
February 28, 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 they are unable to locate any corresponding hospital admission/facility claims for the date of 
service. 
 
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 the denied codes is: 
 
CPT 52330: 
 
Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of ureteral calculus 
 
CPT 52276: 
 
Cystourethroscopy with direct vision internal urethrotomy 
 
CPT 52332: 
 
Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) 
 
CPT 74420: 
 
Urography, retrograde, with or without KUB  
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do validate the provider performed these services. However, the claim was submitted to the 
health plan with a Place of Service 21, noted as in-patient hospital. However, there is no NOA (Notice of 
Admission) to indicate patient was in fact, in-patient. The health plan was unable to cross-reference an in-
patient facility claim filed by the hospital, therefore this in-patient service cannot be verified and does not meet 
criteria for reimbursement consideration. 
 
We looked at this coder'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 pay for emergency room services provided to the enrollee on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
had a stroke in December of 2019 with resulting right paralysis and no movement in your right arm. You are 
requesting a Myomo powered upper extremity range of motion assist device. There is no documentation of 
your rehabilitation or progress in your motor recovery or functional status. There are no physical therapy or 
occupational therapy notes to review. The submitted records do not support that the requested device is the 
standard of care for your condition and it is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a powered upper extremity range of motion assist device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided to the enrollee on May 14, 2019. 
 
You asked the Plan to pay for the services. You say that since the enrollee was in an assisted living facility, the 
doctor was not responsible to get the authorization. The Plan denied your request. The Plan says the services 
are not covered and 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 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 podiatry services provided to the enrollee on May 
14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 3, 2019 and 
October 24, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
covers care received from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan 
 
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 October 3, 2019 and October 
24, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the medical services provided from October 
3, 2019 to March 11, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that the wound is still not 
healed. The Plan denied your request. The Plan says the claims were filed correctly and processed with the 
applicable cost share. 
 
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 documentation shows that the enrollee received emergency room care on October 3, 2019. A $90 copay 
was applied. The services fall within the emergency care benefit category.  
 
The enrollee received a specialist office visit on January 8, 2020. A $30 copay was applied. The services fall 
within the physician services benefit category. 
 
The documentation shows that the enrollee received debridement services on October 30, 2019, November 13, 
20, and 27, 2019. These services are considered outpatient surgery services. The enrollee was charged 20% of 
the total cost for the surgery services.  
 
The enrollee also received debridement services on January 2, 22, 29, 2020, February 5, 12, 19, 2020, and 
March 4 and 11, 2020. The enrollee was charged $262.22 for each date of service. Because the amount is less 
than the $300 copay, the enrollee was charged the lesser amount. The services fall within the outpatient surgery 
benefit category. 
 
The enrollee has been asked to pay the correct amounts 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 cost shares for the medical services provided from October 3, 2019 to March 
11, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided from February 
21, 2020 to February 22, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you don't think you owe the 
charges because you were there one and a half days for a procedure. 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 a $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided from 
February 21, 2020 to February 22, 2020.