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

 
We decided that the Plan does not have to pay for the Percepta Genomic testing rendered on May 24, 2019. 
 
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 not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the Percepta Genomic test is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted records do not support that 
the enrollee's bronchoscopy was non-diagnostic (i.e., actionable benign or malignant diagnosis could not be 
reached). The documentation is insufficient to demonstrate that Percepta Bronchial Genomic Classifier testing 
was medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Percepta Genomic testing rendered on May 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment charged for ambulance transport provided on 
April 23, 2020. 
 
You asked the Plan to waive this copayment. You say that you were taken to the hospital with Covid-19 
symptoms and tested positive for virus, therefore this copayment should be waived. The Plan denied your 
request. The Plan says this copayment was charged based on the Medicare rules and the Plan contract 
agreement. 
 
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 $350 
copayment for ambulance transport.  
 
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. It should be noted that Medicare is 
requiring coverage for Covid related services, but copayments are not being waived for services such as 
ambulance transport. While the service is covered, the copayment stands. Therefore, we decided that the Plan 
does not have to waive the copayment charged for ambulance transport provided on April 23, 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 April 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 car.
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 service 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 services provided to the enrollee on April 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  the CT scan provided on April 29, 2020. 
 
You asked the Plan to waive the copayment for  the CT scan. You say that you were told that the service was 
covered. You say you should not be responsible for the copayment amount. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress 
tests).  
 
You have been asked to pay a $275 copayment for the CT scan. The 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 CT scan provided on April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture with a flexible base provided 
on January 16, 2020. 
 
You asked the Plan to pay for the mandibular partial denture. The Plan denied your request. The Plan says the 
service you received is a partial denture with a flexible base, which is not a covered service. The Plan also says 
the partial dentures that are covered is an acrylic or metal base. 
 
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 Plan only covers removable partial dentures with an acrylic or 
metal base. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture with a 
flexible base provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
December 16, 2019. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided to the enrollee on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wig, any type (A9282) purchased February 16, 2020.
You asked the Plan to pay for the wig. You say that you are requesting review of your claim. The amount of
money spent is a hardship and the purchase was not a luxury but a necessity. The Plan denied your request. The
Plan says this item is not covered. Page 4-59 of the plan's 2020 Evidence of Coverage specifically lists wigs
and their care are not covered under the plan benefits.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for wig, any type (A9282)
purchased February 16, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the bitewing x-rays provided on June 3, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you were not aware that the bitewing x-rays 
would not be covered. The Plan denied your request. The Plan says that your bitewing x-rays benefit had been 
exhausted. The Plan also says that you last received bitewing x-rays on June 10, 2019. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the bitewing x-rays by a contract provider. The file does not show that the Plan provided 
notice that the bitewing x-rays only be covered every 365 days or to the day of the last bitewing x-rays. You 
reasonably believed, because it had been 12 months, that the bitewing x-rays would be covered. Under 
Medicare rules, this means the bitewing x-rays are considered approved by the Plan. Therefore, we decided that 
the Plan has to pay for the bitewing x-rays provided on June 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit (99215). You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says non-emergent services rendered by non-
participating providers in non-participating facilities require prior authorization as outlined in the enrollees 
EOC. 
 
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 18, 
2020 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 on March 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services (90832). You say that you would like reconsideration 
because this provider depends on the hospital staff to verify eligibility and obtain authorization. The Plan 
denied your request. The Plan says non-urgent services should be from network providers who are contracted 
with the health plan and listed in the Provider Directory. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 6, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation provided during a chiropractic visit on 
December 30, 2019. 
 
You asked the Plan to pay for this service. You say that you do not believe this bill is correct. The Plan denied 
your request. The Plan says there is a 4% coinsurance for covered services. Those services not related to 
manual manipulation of the spine, such as electrical stimulation, are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical 
stimulation provided during a chiropractic visit on December 30, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ER visit provided on April 28, 2020. 
 
You asked the Plan to reduce the copayment for an ER visit. You say that you should owe a specialist 
copayment instead because due to COVID-19 you could not be seen at the doctor's office so you were advised 
to go to the ER. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to reduce the copayment for an ER visit provided on April 
28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic for tooth #31 provided on February 18, 2020. 
 
You asked the Plan to pay for the pontic. You say that tooth #31 was extracted in 2009 when you were covered 
under a different Plan. You also say that you thought the procedure would be covered. The Plan denied your 
request. The Plan says this service is not a covered benefit when replacing a tooth that was missing prior to 
coverage being active with 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 initial installation of a bridge to 
replace teeth missing prior to coverage are excluded from coverage. You state that tooth #31 was extracted in 
2009, and your coverage with this Plan was not effective until February 1, 2019. Therefore, we decided that the 
Plan does not have to pay for the pontic for tooth #31 provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the eye exam (92012) rendered by the out of 
network (OON) provider on June 28, 2019. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to issue reimbursement for the eye exam (92012) rendered by the out of network (OON) provider on  
June 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography provided on February 20, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for echocardiography. You say that nursing homes and clinics request services as 
soon as possible so you are unable to get authorization. The Plan denied your request. The Plan says this was 
not authorized and the submitted records are not sufficient to show it was necessary for this service to be 
provided OON. 
 
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 echocardiography provided on February 20, 
2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $325 copayment charged for ambulance transport 
provided on April 24, 2020. 
 
You asked the Plan to waive . You say that you cannot afford this copayment. The Plan denied your request. 
The Plan says this copayment was charged based on the service provided and the Plan contract agreement. 
 
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 $325 
copayment for ambulance transport.  
 
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 $325 copayment charged for ambulance transport provided on April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on November 5, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision services provided on February
28, 2020 and March 24, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you scheduled a routine eye
exam and were advised you would have to come back for additional tests. You state your EOC says that you
have a $0 copayment for annual routine exams. The Plan denied your request. The Plan says the claims were
processed accordingly with your 2020 EOC 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).
Review of the file show that you received the vision services on February 28, 2020 and March 24, 2020. The
services were not routine. You are asked to pay a $40 copayment per date of service for the visions services.
Your EOC states, enrollees must pay a $40 copayment for physician services to diagnose and treat diseases and
conditions of the eye. 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 vision services provided on
February 28, 2020 and March 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service your wife called for 
an ambulance because you had passed out. You say that after the emergency responders had arrived and tended 
to you, you started to appear to be better. The responders told your wife that no one could go with you to the 
hospital due to coronavirus. Because of your conditions, your wife decided that it would be more traumatic for 
you to be transported by yourself and so transport was declined so that she could watch you at home. You say 
that you would have gone to the hospital if your wife was able to go with you, and you asked the Plan to 
reconsider their decision. 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 ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.