Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a visit for eyeglasses provided outside of the United States on December 15, 2019.

You asked the Plan to pay for optometry visit. You say that you had an unexpected severe problem with your eyesight and were advised to see this provider to have new glasses made. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan does not cover eyeglasses except after cataract surgery and this service is not considered urgent or emergent.

The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the United States are not covered by Medicare except in certain, specific circumstances. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers worldwide coverage and routine vision benefits that exceed Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers worldwide urgent and emergent care when medical services are needed right away for an illness, injury, or condition you did not expect, and you cannot wait until you return to the Plan's service area to obtain service. The Plan does not cover routine eyewear.

We looked at the file and Medicare rules. Routine eyewear is not covered by Medicare or the Plan, therefore this routine eyewear visit would not be covered by the Plan's worldwide coverage benefits. Based on this information, we decided that Medicare rules for coverage of optometry visit have not been met. Therefore, we decided that the Plan does not have to pay for a visit for eyeglasses provided outside of the United States on December 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist/hand orthoses provided to the enrollee on December 23, 2019.

You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says that the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the wrist/hand orthoses provided to the enrollee on December 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammography, including 
computer aided detection when performed  (77066) provided January 11, 2019. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that per the 2019 plan 
materials book page 4-9 there is no coinsurance, copayment or deductible for covered screening mammograms. 
Please refund your $100 copay. The Plan denied your request. The Plan says this claim was processed correctly 
and the correct cost share 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 $100 
copayment for each Medicare covered radiological diagnostic service for Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You have been asked to pay $100 copayment for the diagnostic mammogram. The diagnostic mammogram 
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 the diagnostic mammography, including computer aided detection 
when performed (77066) provided January 11, 2019.
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 March 16, 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 Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for bile duct cancer. 
 
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 services 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 March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit to the patient's assisted living facility provided on 
November 27, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the physician visit. You say that the facility was responsible for getting 
authorization for these services. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
Neither the provider in this case nor the assisted living facility where the services were rendered is 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 visit to 
the patient's assisted living facility provided on November 27, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on September 25, 2019. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code should be entered adjacent to the code in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on September 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 14301) provided to the enrollee on 
February 10, 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 CPT 14301 is not supported by the medical records submitted. 
 
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 14301 is 'adjacent tissue transfer or rearrangement, any 
area; defect 30,1 sq cm to 60.0 sq cm.' 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
operative report did not include adjacent tissue transfer or rearrangement, any area; defect 30, 1 sq cm to 60.0 
sq cm. 
 
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 pay for surgical services (CPT 14301) provided to the enrollee on February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper and lower denture provided on March 6, 
2020. 
 
You asked the Plan to pay for the complete upper and lower denture. You say that the claim should be 
reprocessed and paid. The Plan denied your request. The Plan says you had no dental coverage at the time of 
service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the complete upper and lower 
denture provided on March 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and 
management of an established patient. Typically, 40 minutes are spent with the patient and/or family or 
caregiver. (CPT Code 99336) provided to the enrollee on April 14, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says the service provided appears to have been and elective 
skilled nursing facility (SNF) stay by a non-participating provider. The Plan states there is no documentation 
provided in support of why the member needed to see non-participating provider when it's likely that 
participating providers were available. 
 
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 domiciliary or rest home visit for the evaluation 
and management of an established patient. Typically, 40 minutes are spent with the patient and/or family or 
caregiver. (CPT Code 99336) provided to the enrollee on April 14, 2020 by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bone and joint scan (78306) performed on 
March 2, 2020. 
 
You asked the Plan to waive the copayment for a bone and joint scan. You say that you have already paid a $95 
copayment and should not be charged again. 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 Medicare-covered diagnostic and nuclear medicine radiological services, excluding 
mammography and ultrasounds. The Plan contract also says that if multiple test types (such as CT and PET) are 
performed in the same day, multiple copayments will apply. 
 
The case record indicates that your previous copayment of $95 was a charge for a CT scan received on the 
same date of service. You have also been asked to pay a $95 copayment for a bone and joint scan. A bone and 
joint 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 bone and joint scan (78306) performed on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0210) provided on January 21, 2020. 
 
You asked the Plan to pay for the intraoral x-ray (D0210). You submitted your bills for review. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
intraoral x-ray (D0210) provided on January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation on March 26, 
2020. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you are on a fixed 
income and cannot afford this. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. 
 
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 $195 
copayment for ambulance transportation.  
 
You have been asked to pay $195 copayment for ambulance transportation. Ambulance transportation falls 
within the Ambulance 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 
ambulance transportation on March 26, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chiropractic service provided on October 22, 2019. 
 
You asked the Plan to waive the coinsurance for chiropractic service. You say that you were told that you 
would have no cost-share, and do not understand why the Plan did not pay this amount. The Plan denied your 
request. The Plan says that the coinsurance amount you are being charged is correct. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for chiropractic services.  
 
We looked at your contract with the Plan. The contract does not clearly say that enrollees must pay 20% 
coinsurance for chiropractic services. The Plan contract says that enrollees pay 0% or 20% coinsurance for 
chiropractic services but does not clearly disclose when enrollees should expect to pay 0% coinsurance and 
when enrollees should expect to pay 20% coinsurance. This means that the Plan did not follow Medicare rules 
for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for 
chiropractic service provided on October 22, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 18, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered. The Plan 
denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider 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 medical services provided on March 18, 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on February 10, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the patient was not aware of where the lab 
services would be performed, so this should be covered. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
Neither the provider of the services in this case nor the ordering provider is 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 pathology services 
provided on February 10, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from January 8, 2020 to 
January 29, 2020. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have looked for quite a while for a 
psychologist that would fit your specific needs and you have had an excellent patient/provider relationship for 
over a year. The Plan denied your request. The Plan says you must receive care 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 psychotherapy services provided from January 8, 2020 to 
January 29, 2020.