Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on February 3, 2020 to February 11, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these 
copayments. The Plan denied your request. The Plan says the correct copayments have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $20 copayment for each visit for physical therapy. The total amount you are 
being asked to pay is $120 ($20 x 6 visits = $120). The correct copayments have been applied to the services 
that were provided. Physical therapy 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 physical therapy provided by a participating provider on 
February 3, 2020 to February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the neuropsychological testing and 
evaluation services (96133,96116,96132, 96136) provided on February 25, 2020. 
 
You asked the Plan to adjust the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 
has been applied correctly to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for diagnostic tests and procedures provided in an outpatient department of a hospital.  
 
You have been asked to pay a $50 copayment for the diagnostic testing provided in an outpatient hospital 
setting. 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 adjust the copayment for the neuropsychological testing and evaluation 
services (96133,96116,96132, 96136) provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit you had on May 4, 2020. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is you second wellness 
visit in the last 12 months. 
 
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 $0 
copayment for an annual wellness visit once every 12 months.  
 
Review of the file shows that you had an annual wellness visit on May 4, 2020. The records also show that you 
had a covered wellness visit on January 6, 2020. The requested visit exceeds the benefit limit as the services 
were provided less than 12 months after your covered wellness visit. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have 
to pay for the annual wellness visit you had on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home physical therapy services provided on November 1, 
2019 and November 5, 2019 billed with two units of 97530 and two units of 97112 for each date. 
 
You asked the Plan to pay for the physical therapy services. You say that these services should be paid as they 
were medically necessary. The Plan denied your request. The Plan says the therapy note does not clearly 
document the time spent providing this care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that two units of these codes are not supported in the medical record. The medical record does not 
document the time spent, so it cannot be confirmed that 30 minutes were spent on each of these services. Based 
on this information, we decided that Medicare rules for coverage of the physical therapy services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home physical therapy services provided 
on November 1, 2019 and November 5, 2019 billed with two units of 97530 and two units of 97112 for each 
date.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for applications of a skin graft (15271) 
performed on April 10 and April 28, 2020. 
 
You asked the Plan to waive the copayment for applications of a skin graft. You say that you should not be 
charged the copayment twice. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each Medicare-covered hospital facility visit.  
 
You have been asked to pay a $300 copayment for applications of a skin graft. An application of a skin graft 
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 applications of a skin 
graft (15271) performed on April 10 and April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit you had on March 13, 2020. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this visit exceeds the 
benefit limit. 
 
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 $0 
copayment for an annual wellness visit once every 12 months.  
 
Review of the file shows that you had an annual wellness visit on March 13, 2020. The records also show that 
you had a covered annual wellness visit on March 6, 2019. The requested visit was provided less than 12 
months after your covered 2019 visit, which exceeds the benefit limit. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have 
to pay for the annual wellness visit you had on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided from April 25, 2019, to 
May 1, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 the drug testing services provided from April 25, 2019, to May 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit, CT of the maxillofacial area, 
implant removal, drainage of mouth lesion, first 15 minutes of deep sedation/general anesthesia, each 
subsequent 15 minute increment of deep sedation/general anesthesia, and therapeutic, prophylactic, or 
diagnostic injection provided on May 1, 2020 and May 6, 2020 by an OON provider. 
 
You asked the Plan to pay for the office visit, CT of the maxillofacial area, implant removal, drainage of mouth 
lesion, deep sedation/general anesthesia services, and therapeutic, prophylactic, or diagnostic injection. You 
say that your dentist referred you to an oral surgeon to perform the procedure because your jaw was broken. 
The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also 
says that prior authorization was not obtained. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
 
 
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit, CT of the maxillofacial area, implant removal, drainage of mouth lesion, first 15 minutes 
of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, 
and therapeutic, prophylactic, or diagnostic injection provided on May 1, 2020 and May 6, 2020 by an OON 
provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the measurement of post-voiding residual urine and/or 
bladder capacity by ultrasound (51798) provided on February 18, 2020. 
 
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says only the facility may be reimbursed for the Technical 
Component of the service or procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology and other diagnostic services furnished 
to hospital outpatients are paid under OPPS to the hospital.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have not been met. Specifically, per Medicare, CPT code 51798 has a 
professional/technical indicator of 3. This means that CPT code is a technical only code and the technical 
component of diagnostic services are paid to the facility. Therefore, we decided that the Plan does not have to 
pay for the measurement of post-voiding residual urine and/or bladder capacity by ultrasound (51798) provided 
on February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on April 9, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you 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 a $225 
copayment for diagnostic radiology services provided in a free-standing clinic.  
 
You have been asked to pay the allowed amount of $131.93, which is less than the $225 copayment for a CT 
scan. A CT 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 CT scan provided on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on 
September 13, 2019. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says testing is not covered for pancreatic cancer. 
 
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 pay for the testing. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found 
Guardant360 is used for detecting Non-Small Cell Lung Cancer (NSCLC) in patients with advanced NSCLC. 
Guardant360 does not have an FDA-approved or FDA-cleared indication for use in this enrollee's cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided to the enrollee on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 24, 
2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services you received on July 25, 2019, and September 12, 2019.
You asked the Plan to waive the copayments. The Plan denied your request. The Plan says you are responsible for the copayments.
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 $40 copayment for each visit for specialist services. Review of the file shows that you were provided specialist services on July 25, 2019, and September 12, 2019. You have been asked to pay a $40 copayment for each visit. The services fall within the physician 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 copayments for the specialist services you received on July 25, 2019, and September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (71045) provided on March 16, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because multiple x-
rays were rendered on the billed date of service. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
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 71045 is not supported in the record. Specifically, per Medicare guidance, services 
performed on the same date of service should be billed on one claim. Additionally, the time of day for each 
service is not noted on the claim. Based on this information, we decided that Medicare rules for coverage of the 
chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray 
(71045) provided on March 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided by
participating providers on February 18, 2020 to February 28, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you paid your copay prior to
treatment. The Plan denied your request. The Plan says the correct copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for outpatient surgery/outpatient hospital facility.
You have been asked to pay a $300 copayment for each outpatient surgery. The total amount you are being
asked to pay is $600 ($200 x 2 surgeries = $600). The correct copayments have been applied for the services
provided. Outpatient surgery falls within the outpatient surgery/outpatient hospital facility 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 surgery provided by participating providers on
February 18, 2020 to February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of skin lesion (11643) 
provided December 20, 2019. 
 
You asked the Plan to waive the copayment for the removal of skin lesion. You say that you had your right 
cheek cut, and cancer cells removed from inside the check and then stitches to close the skin. You do not 
understand why such a procedure would not be covered. The Plan denied your request. The Plan says the claim 
was processed correctly and the correct copayment for specialist physician services 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 $30 
copay for each specialist visit.  
 
You have been asked to pay $30 copay for each specialist visit. The removal of skin lesion falls within the 
Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the removal 
of skin lesion (11643) provided December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on March 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (71045) provided on March 16, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service 
was rendered multiple times on the billed date of service. The Plan denied your request. The Plan says this is a 
duplicate claim. 
 
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 71045 is not supported in the record. Specifically, per Medicare guidance, services 
performed on same date of service should be reported on the same claim. Additionally, there is no time of day 
indicated on the claim form. Based on this information, we decided that Medicare rules for coverage of the 
chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray 
(71045) provided on March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 10, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that the enrollee did not physically attend your facility, 
and you do not have the information about the enrollee's insurance requirements, limitations, or conditions. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and the referring provider is also out-of-network with 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 10, 
2020 by an out of network (OON) provider.