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

We decided that the Plan has to pay for Guardant360 testing provided on June 29, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing is a covered benefit. The Plan denied your request. The Plan says that this service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Guardant360 testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found Molecular Diagnostic Studies in Non-Small Cell Lung Cancer (NSCLC) are considered a 
standard of care. Testing of lung cancer specimens for these alterations is important for identification of 
potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit.  
 
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 Guardant360 testing have been met. Therefore, we decided that the Plan has 
to pay for Guardant360 testing provided on June 29, 2020.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider.

You asked the Plan to waive the copayment for an outpatient surgery. 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 $260
copayment for outpatient surgery/in-network.

You have been asked to pay $255.60 which is less than your copayment amount of $260 for each outpatient
surgery. The total amount you are being asked to pay is $1,533.60 ($255.60 x 6 surgeries = $1,533.60). An
outpatient surgery falls within the outpatient surgery/in-network 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 outpatient surgery provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and comprehensive oral 
evaluation provided on October 14, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and comprehensive oral evaluation. You say 
that your previous provider who retired referred you to this new provider. You also say that you feel these 
services should be covered because it is not your fault that your previous provider retired. The Plan denied your 
request. The Plan says the first intraoral periapical x-ray is not a covered service. The Plan also says that your 
benefits for the comprehensive oral evaluation have been satisfied and the frequency limitation has been 
exceeded. 
 
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 first intraoral periapical x-ray is not 
among those covered under this benefit. The Plan contract says that comprehensive oral evaluation is limited to 
one procedure every three years. The record shows that you received a comprehensive oral evaluation on June 
16, 2020, and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the first intraoral periapical x-ray and comprehensive oral evaluation provided on 
October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for home international normalized ratio (PT/INR) testing provided by an out of network (OON) provider.

You asked the Plan to pay for home INR testing. You say that you were not aware that this provider was out-of-network. 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 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 home international normalized ratio (PT/INR) testing provided by an out of network (OON) provider.
Appeal type: Practitioner Services
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 September 23, 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 had network providers 
available who could have provided 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 September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider.

You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied to the injection that was 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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The allowed amount is $1,194.06. The total amount you are being asked to pay is $238.81 ($1,194.06 x 20% = $238.81). The correct coinsurance has been applied to the services that were provided. An injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for chemical dependence visit. You say that there was no time to submit a prior authorization request because you were put in this facility overnight. 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 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 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral
periapical x-ray, and preventive procedure.

You asked the Plan to pay for the intraoral periapical x-rays and preventive procedure. You say that you confirmed with a Plan representative that this provider was in-network. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray, additional intraoral periapical x-ray, and preventive procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness equipment you purchased on June 20, 2020 
 
You asked the Plan to pay for the fitness equipment. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers gym benefits 
up to $300 per year. 
 
The Plan's rules for coverage of gym benefits have not been met because fitness equipment is not covered 
under your plan. A COVID-19 exception was made for fitness equipment by the Plan from October 1, 2020, to 
December 31, 2020, but this equipment was not purchased during the exception period. Therefore, we decided 
that the Plan does not have to pay for the fitness equipment you purchased on June 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. You say that you were not told that this provider was not
a participating provider. The Plan denied your request. The Plan says the services were obtained out-ofnetwork
and were not authorized by 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pest extermination services.

You asked the Plan to pay for the extermination services. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The extermination services were not reasonable and necessary for the diagnosis or treatment of an illness or injury. Based on this information, we decided that Medicare rules for coverage of the extermination services have not been met. Therefore, we decided that the Plan does not have to pay for the pest extermination services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

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 admission is 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 required moderate assistance to sit up and lie down. The enrollee
required contact guard assistance to stand up and sit down. The documentation does not support that the
enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The
enrollee's care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from July 7, 2020, to August 31, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
Medicare certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services you received from July 7, 
2020, to August 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that given lack of skilled medical or therapy needs, patient should be able to 
discharge back to home or to long term care with appropriate custodial support. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274).

You asked the Plan to pay for the bitewings. You say that you do not feel that you should be liable for this service. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.

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, bitewings are limited to one of codes D0270, D0272, D0273, D0274, or D0277 once per plan year. The record shows that you received bitewings (D0274) on May 30, 2020, and your bitewings benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings (D0274).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider from July 24, 2020, to August 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 you by an out-of-network 
provider from July 24, 2020, to August 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services.

You asked the Plan to pay for the transportation services. You say that you needed to see your orthopedic doctor. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the transportation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for destruction by neurolytic agent.

You asked the Plan to waive the copayment for destruction by neurolytic agent. You say that you have had this procedure before with no copayment so you should not have a copayment now. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $350 copayment for Outpatient Surgery.

You have been asked to pay a $350 copayment for destruction by neurolytic agent. Destruction by neurolytic agent falls within the Outpatient Surgery 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 destruction by neurolytic agent.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services.

You asked the Plan to pay for the molecular pathology services. You say that you would like reconsideration
because this is payable by Medicare. The Plan denied your request. The Plan says this service was not billed
correctly.

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 molecular pathology services. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the member does not have a diagnosis which is covered per the LCD.

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 molecular pathology services have not been met. Therefore, we decided that
the Plan does not have to pay for molecular pathology services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Myocardial perfusion imaging, 
tomographic (SPECT) provided October 23, 2020. 
 
You asked the Plan to waive the copayment for the radiology imaging services. You say that you never had to 
pay a radiology copay before. You did not like that you were not told about it at the time of service. You 
believe it should be covered by the plan. The Plan denied your request. The Plan says this claim was processed 
and the correct copayment was applied per the Evidence of Coverage. 
 
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 up to a maximum of $75 per day for diagnostic services.  
 
You have been asked to pay $75 for the radiology imaging services. The radiology imaging services 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 Myocardial perfusion imaging, tomographic (SPECT) provided 
October 23, 2020.