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

 
We decided that the Plan does not have to pay for the Guardant 360 testing provided on May 11, 2020. 
 
You asked the Plan to pay for the Guardant 360 testing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the Guardant 360 testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant 360 testing provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordermatology services provided on June 23, 2020 by an out of network (OON) provider.You asked the Plan to pay fordermatology services. You say that you were not able to see an approved provider within a timely period so you would like to be reimbursed for the out-of-network costs you incurred.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.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 fordermatology services provided on June 23, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Cxbladder testing provided on December 11, 2019.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says this is not medically necessary.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 requested Cxbladder testing is not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard is using cystoscopy yearly for this type of case. The Cxbladder test has no other high quality evidence besides one study found in the available literature, and no current guidelines recommend this test at this stage. This test should be considered investigational. There were no clear contraindications to having cystoscopy to support going outside current guidelines.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 forthe Cxbladder testing provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on July 7, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you only had an EKG. The 
Plan denied your request. The Plan says the correct copayment has 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 $15 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $15 copayment for a specialist office visit. Since a specialist office visit was 
provided, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/specialist 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 specialist office visit provided by a participating provider on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99202) provided on  
May 28, 2020. 
 
You asked the Plan to waive the copayment. 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 service 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 $15 
copayment for each covered office visit to other providers for urgently needed services. 
 
You have been asked to pay a $15 copayment for the office visit to a provider for urgently needed services. 
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 office visit (99202) provided on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on May 12, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479.  Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye refraction (92015) provided on December 13, 
2019. 
 
You asked the Plan to pre-approve the eye refraction. You say that you would like reconsideration because you 
already paid the copayment for this service. The Plan denied your request. The Plan says Medicare does not 
cover routine eye exams (eye refractions). 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 supplemental routine eye exam per year.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. Specifically, eye refractions are not a Medicare covered 
benefit. Therefore, we decided that the Plan does not have to pre-approve an eye refraction (92015) provided 
on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided by a neuromuscular therapist provided on 
January 31, 2020. 
 
You asked the Plan to pay for the services provided by a neuromuscular therapist. You say that the provider is a 
neuromuscular therapist who works better than a doctor prescribed therapist for your back. You say that the 
plan covered therapist who you saw two or three years ago did not correct your problem. You say that the 
neuromuscular therapist worked on your and gave you immediate relief. You say that you are looking to be 
reimbursed the wellness allowance amount, and not the full amount on the receipt. The Plan denied your 
request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist or a 
neuromuscular therapist. Therefore, we decided that the Plan does not have to pay for services provided by a 
neuromuscular therapist provided on January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab work provided by a participating 
provider on June 1, 2020. 
 
You asked the Plan to waive the deductible for lab work. You say that this should all be covered with your 
annual wellness exam. The Plan denied your request. The Plan says the correct deductible amount has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible for outpatient diagnostic tests/laboratory tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests/laboratory tests. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $250 deductible for outpatient diagnostic tests/laboratory tests. The total amount you are being asked 
to pay is $75.10. This cost sharing is a contractual obligation that had not been met at the time lab work was 
received on June 1, 2020. Therefore, we decided that the Plan does not have to waive the deductible for lab 
work provided by a participating provider on June 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram (93226) provided February 7, 2020.You asked the Plan to waive the copayment forthe electrocardiogram. You say that the copayment should be waived.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 $90 copayment for Diagnostic Testing. You have been asked to pay a $39.80 copayment for the electrocardiogram. The electrocardiogram falls within the Diagnostic Testing benefit category. In this case, the Medicare allowable amount of $39.80 is less than the $90 noted in the Evidence of Coverage. 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 foran electrocardiogram (93226) provided February 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pembrolizumab injection (J9271) 
provided on June 3, 2020. 
 
You asked the Plan to waive the copayment for the injection. You say that you would like this copayment 
waived because the member was not aware of how costly the treatments would be and they are unable to afford 
the treatment. The Plan denied your request. The Plan says the member is responsible for a 20% coinsurance 
for Medicare Part B non-chemotherapy prescription drugs. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B Prescription Drugs.  
 
The member has been asked to pay $3,290.60. The allowed amount for this service is $20,0008. 20% of 
$20,0008 is $4,001.6. This means that the member has been asked to pay less than the contracted amount. 
 
The enrollee has been asked to pay less than a 20% coinsurance for the injection. The injection falls within the 
Medicare Part B Prescription Drugs benefit category. This means that the enrollee has been asked to pay less 
than the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the pembrolizumab injection (J9271) provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on May 11, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that the second surgery would not 
have been necessary if it were not for the mistakes made by the doctor in the first surgery. The Plan denied 
your request. The Plan says the correct copayment has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment for physician/practitioner services/in-network/provider services/specialist.  
 
The enrollee has been asked to pay a $45 copayment for specialist services. Specialist services fall within the 
physician/practitioner services/in-network/provider services/specialist benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for specialist services provided by a participating provider on May 11, 
2020.  
 
We note your complaint about having problems from the first surgery. Your complaint is a grievance that must 
be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a duplex scan provided by a participating 
provider on March 2, 2020. 
 
You asked the Plan to waive the coinsurance for a duplex scan. You say that you do not agree with this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance has 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% 
coinsurance for outpatient diagnostic tests/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a duplex scan. The total allowed 
amount is $370.96. The total amount you are being asked to pay is $74.17 ($370.96 x 20% = $74.17). A duplex 
scan falls within the outpatient diagnostic tests/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 coinsurance for a duplex scan provided by a participating provider on March 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided May 14, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that you went home from the hospital in a taxi and paid $25. You do not know why you would be billed by an ambulance company if you never even used an ambulance to get home from the hospital.The Plan denied your request. The Plan says you were charged this cost sharing 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 $325 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $325 for these services. 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 forthe ambulance services provided May 14, 2020
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab services provided on April 21, 2020. 
 
You asked the Plan to waive the deductible for lab services. You say that you have not been charged this much 
in the past. The Plan denied your request. The Plan says the deductible you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible for covered in-network medical services. The 
allowed amounts of these claims for lab services total $133.20, resulting in a deductible obligation of $133.20. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $300 deductible for covered in-network medical services. This cost 
sharing is a contractual obligation that had not been met at the time lab services were received on April 21, 
2020. Therefore, we decided that the Plan does not have to waive the deductible for lab services provided on 
April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider on May 12, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that this was blood work and you shouldn't 
have a copayment for blood work. The Plan denied your request. The Plan says the correct copayment has 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 $10 
copayment for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a $10 copayment for lab work. The correct copayment has been applied to the lab 
work that was provided. Lab work falls within the outpatient diagnostic tests/laboratory 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 lab work provided by a participating provider on May 12, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric services.You asked the Plan to pre-approvethe inpatient psychiatric services. You say that the records provided support the need for inpatient psychiatric care.The Plan denied your request. The Plan says the clinical information provided does not support the inpatient level of care. The Plan says that the enrollee can be treated in a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 the inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on September 19, 2020 with Major Neurocognitive Disorder with Behavioral Disturbance. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. 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 inpatient psychiatric services have not beenmet.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (92012) provided on 
April 14, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the enrollee should not be 
charged for this service. The Plan denied your request. The Plan says this processed 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment for each specialist office visit.  
 
The enrollee has been asked to pay a $45 copayment for a specialist office visit. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a specialist office visit (92012) provided on April 14, 2020.  
 
Your complaint about the enrollee needing this service due to the doctors error is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.