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

 
We decided that the Plan does not have to waive the copayment for the lipid panel provided by an out of 
network provider on October 7, 2019. 
 
You asked the Plan to waive the copayment for the lipid panel. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services were processed correctly per 
your plan benefits. 
 
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 $30 
copayment for each Medicare covered diagnostic procedure, test and/or lab service when provided by an out of 
network provider.  
 
You have been asked to pay a $30 copayment for the lipid panel. The lipid panel falls within the out of network 
outpatient diagnostic tests 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 lipid 
panel provided by an out of network provider on October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of extracranial arteries 
(93882) performed on May 6, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of extracranial arteries. You say that this should 
be fully covered as preventive care. 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $101.50 copayment for an ultrasound of extracranial arteries. An ultrasound of 
extracranial arteries falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 
benefit category. This means that you have been asked to pay less than the full 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 ultrasound of extracranial 
arteries (93882) performed on May 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on May 11, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says skilled services were no longer necessary. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee no longer qualified for SNF 
coverage on 5/11/2020. The enrollee did not have documented skilled nursing needs. The enrollee did not have 
documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program 
or to prevent deterioration of the enrollee's condition. 
 
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 skilled nursing facility (SNF) services provided to the enrollee on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided on April 26, 2020. 
 
You asked the Plan to pay for the Guardant360 test. You say that the test was medically necessary. The Plan 
denied your request. The Plan says service providers should use one CPT code not unbundle the test to separate 
codes. 
 
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, we have confirmed that the 
Guardant360 test uses one code, 81479, and cannot be paid as billed. This code cannot be paid as separate line 
items. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 test provided on April 26, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an ER visit provided on August 11, 2019. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were admitted to the hospital 
within 24 hours of the ER visit so the copayment should be waived. The Plan denied your request. The Plan 
says that the claims were processed correctly and you are being charged the correct amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records. Without medical records we cannot 
determine whether or not you were admitted inpatient within 24 hours of the ER visit. Therefore, we decided 
that the Plan has to waive the copayment for an ER visit provided on August 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on March 10, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. 
 
The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does 
not have to pay for the Cxbladder testing rendered on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80048, 85025, P9604) 
rendered by the out of network (OON) provider on May 13, 2020. 
 
You asked the Plan to pay 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 services were rendered by an out of 
network provider, without 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 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 laboratory services (36415, 80048, 85025, P9604) rendered by the out of network 
(OON) provider on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections of the lower or sacral spine 
(64493 and 64494) performed on May 20, 2020. 
 
You asked the Plan to waive the copayment for injections of the lower or sacral spine. You say that you 
shouldn't have to pay this bill because the shots you were given were totally ineffective. 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 $250 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $250 copayment for injections of the lower or sacral spine. Injections of the 
lower or sacral spine fall 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 injections of the lower or sacral spine (64493 and 64494) performed on May 20, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided on April 7, 2020. 
 
You asked the Plan to pay for the Guardant360 test. You say that the test was medically necessary. The Plan 
denied your request. The Plan says service providers should use one CPT code not unbundle the test to separate 
codes. 
 
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, we have confirmed that the Guardant360 test uses one code, 81479, and cannot be paid as billed. 
This code cannot be paid as separate line items. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 test provided on 
April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided on October 30, 2019. 
 
You asked the Plan to pay for the Guardant360 test. You say that the test was medically necessary. The Plan 
denied your request. The Plan says service providers should use one CPT code not unbundle the test to separate 
codes. 
 
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, we have confirmed that the Guardant360 test uses one code, 81479, and cannot be paid as billed. 
This code cannot be paid as separate line items. Based on the claim submitted, Medicare billing criteria have 
not been met.t. Therefore, we decided that the Plan does not have to pay for the Guardant360 test provided on 
October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay from January 2 
to January 3, 2020. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that your stay was 
incorrectly coded. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for each Medicare-covered hospital stay.  
 
You have been asked to pay $1,160.39, or 20% coinsurance of the Plan-allowed amount of $5,801.96, for an 
inpatient hospital stay. An inpatient hospital stay falls within the "Inpatient Hospital 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 coinsurance for an inpatient hospital stay from January 2 to January 3, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) purchased on 
January 8, 2020. 
 
You asked the Plan to pay for a portable oxygen concentrator. You say that you needed to purchase this 
because the in-network companies are lower quality. The Plan denied your request. The Plan says only rented 
equipment is covered. 
 
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-
covered. 
 
We looked at the file and Medicare rules. The record shows that the item at issue was purchased rather than 
rented. Based on this information, we decided that Medicare rules for coverage of a portable oxygen 
concentrator have not been met. Therefore, we decided that the Plan does not have to pay for a portable oxygen 
concentrator (E1392) purchased on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from October 8, 2019 to October 25, 2019. 
 
You asked the Plan to pay for IRF care. You say that the patient was not able to be discharged any sooner. The 
Plan denied your request. The Plan says the enrollee could not tolerate intensive therapy. 
 
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 pay for IRF care. Our reviewer says that the IRF 
care at issue is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient did not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports 
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation 
therapy program. It was well documented that the patient could not tolerate an intensive rehabilitation program. 
 
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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided from October 8, 2019 to 
October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2752) and prefabricated post and core in 
addition to crown (D2954) provided on February 3, 2020 and February 19, 2020. 
 
You asked the Plan to pay for the crown and prefabricated post and core. You say that your Evidence of 
Coverage states that you pay 70% for restorative services received out-of-network. You also say that the 
Evidence of Coverage clearly states that these services are covered. The Plan denied your request. The Plan 
says these services are not covered benefits under your plan. 
 
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 crown 
(D2752) and prefabricated post and core in addition to crown (D2954) provided on February 3, 2020 and 
February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 15, 2020 by an out of 
network (OON) provider. 
 
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 services were rendered by an out-of-network provider without 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 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 April 15, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided on June 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that nothing in your materials says anything more 
than two oral exams. You say that it does not state that it has to be routine oral exams. The Plan denied your 
request. The Plan says the services are not a covered benefit under the plan. 
 
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 services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pay for limited oral 
evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided on 
June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 3, 
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 for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (G0157, G0151) provided from 
April 5, 2019 to May 24, 2019. 
 
You asked the Plan to pay for physical therapy services. You say that these claims should be reprocessed. The 
Plan denied your request. The Plan says these services were provided by a provider that does not participate in 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider of the services at issue is not enrolled in the Medicare 
program. Based on this information, we decided that Medicare rules for coverage of physical therapy services 
have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services 
(G0157, G0151) provided from April 5, 2019 to May 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on February 13, 
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 for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 to the enrollee on February 13, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive one of two ambulance copayments charged for transport 
provided on April 18, 2020. 
 
You asked the Plan to waive an ambulance transport copayment. You say that you were transported by 
ambulance twice in one day. The second transport was from one facility to another because they lacked 
equipment for your treatment. You state that you should not have to pay for the second ambulance transport. 
The Plan denied your request. The Plan says you were charged each copayment based on the claim submitted 
by the provider and the Plan contract agreement. The Plan was billed for two transports and the Plan paid for 
two transports, minus your copayment expectations.  
 
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 $250 
copayment for each transport. The Plan paid for two transports. 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 one of two ambulance 
copayments charged for transport provided on April 18, 2020.