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

We decided that the Plan does not have to pay for a magnetic resonance angiography, head provided on November 20, 2019.
You asked the Plan to pay for the magnetic resonance angiography, head. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 and the referring provider are not network providers with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a magnetic resonance angiography, head provided on November 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by 
participating providers on April 13, 2020 to April 16, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that your daughter was not able to 
take you due to the pandemic. 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 $180 
copayment for ambulance services.  
 
You have been asked to pay a $180 copayment for ambulance services. The total amount you are being asked 
to pay is $360 ($180 x 2 trips = $360). Ambulance services fall within the ambulance services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for ambulance services provided by participating providers on 
April 13, 2020 to April 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization inpatient care provided from 10:01 AM 
on February 9, 2020 to February 11, 2020. 
 
You asked the Plan to pay for the post stabilization inpatient care. You say that  The Plan denied your request. 
The Plan says that the medical records demonstrate the enrollee's emergency medical condition was stabilized 
by 10:01 AM on 02/09/20 such that it met the Medicare standard for transferability. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization inpatient care. Our 
reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case. The 
review has determined that the the treating physician did not document (in the physician notes, on a form, or in 
an order) that the patient was not stable for transfer on any dates of service. Our physician reviewer found that 
the enrollee was hemodynamically and neurologically stable for ambulance transport with monitoring to a Plan 
facility. 
 
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 post stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for the post stabilization inpatient care provided from 10:01 AM on February 
9, 2020 to February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the six extractions provided on February 18, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the extractions. You say that before this provider rendered the services, he should 
have contacted the Plan regarding his network status. The Plan denied your request. The Plan says the treating 
provider is not under contract with your plan. The Plan also says that no benefits are available for procedures 
performed by OON providers or outside of the providers contracted period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the six 
extractions provided on February 18, 2020 by an OON provider.  
 
Your complaint about your dissatisfaction with the Plan and the providers 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ultrasound extremity study and 
behavioral assessment provided on March 2, 2020. 
 
You asked the Plan to waive the copayments for ultrasound test and behavioral test. You say that you were not 
told about any copayments for these services. The Plan denied your request. The Plan says the copayment 
amounts you are being charged are correct. 
 
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 $155 
copayment for ultrasound test and $30 copayment for behavioral test. You have been asked to pay the allowed 
amount of $104.06 for the ultrasound test, because this amount is less than the $155 copayment for an 
ultrasound. You have also been asked to pay the allowed amount of $3.91 for the behavioral test, because this 
is less than the $30 copayment for non-radiological diagnostic tests. Your total copayment obligation is 
therefore $107.97. 
 
You have been asked to pay less than $155 copayment for ultrasound test and $30 copayment for behavioral 
test. Ultrasound test and behavioral test fall 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 copayments for an ultrasound extremity 
study and behavioral assessment provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that the combination of your work and medical history, including two major surgeries, has led to you to experience increasing pain in your feet. You say that you saw a foot specialist who recommended the orthotics for you. You received a bill from the provider for the entire cost of the orthotics because the Plan denied coverage for the services. You say that even though you are not diabetic, you believe that the suffering you have experienced is at least equal to that of which a diabetic individual encounters. You asked the Plan to reconsider providing coverage for the orthotics because you believe that they are medically necessary for you. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office services provided on February 12, 2020.
You asked the Plan to waive the copayment for the specialist office services. You say that this was a yearly routine checkup. The Plan denied your request. The Plan says the services were not coded as a preventative visit.
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 specialist office services on February 12, 2020. You are asked to pay a $25 copayment for the specialist office visit. Your EOC states, enrollees must pay a $25 copay for each Medicare-covered specialist office visit. 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 specialist office services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $386.22 due to overpayment of the maximum out of 
pocket (MOOP) for 2019. You asked the Plan to reimburse you for what you believe is an overpayment of your maximum out of pocket (MOOP) for 2019. You say that based on your calculations for services provided under Medicare Parts A, B and D, you believe you overpaid the out of pocket maximum by $386.22. The Plan denied your request. The Plan says based on their calculations, your out of pocket for 2019 was $3,133.12. The Plan states it should be noted that the Part D expenditures you mention in your appeal are not calculated in the $3400 MOOP. 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 your maximum out of pocket (MOOP) for 2019 was $3400 for Part A and Part B services. The Plan contract also states that there are some services, which are noted on the Explanation of Benefits that are not applied to the MOOP. The Plan contract further notes that expenditures for Part D are not included in the $3400 MOOP. The Plan has provided documentation to show what your expenditures were for Medicare Part A and Medicare Part B services. Your MOOP for 2019 was $3, 133.12. Keep in mind your Part D expenditures would not be deducted or applied to this amount. Therefore, we decided that the Plan does not have to reimburse you $386.22 due to overpayment of the maximum out of pocket (MOOP) for 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 19, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing NEXT-Generation requires use of CPT 81479. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on January 21, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on January 21, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 5, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were 
provided as part of your annual physical and you should not be responsible for the charges. The Plan denied 
your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment laboratory tests.  
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on March 5, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the CT scans and the PET scan provided 
from April 1, 2019 to November 22, 2019. 
 
You asked the Plan to waive the copayments for the CT scans and the PET scan. You say that you are disputing 
your copayments for the services and send your bills in for review. 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 $50 
copayment for each complex procedure, test, and radiology except PET scans and a $200 copayment for each 
PET scan.  
 
You have been asked to pay a $50 copayment for each of the CT scans and a $200 copayment for the PET 
scan. ($50 x 4 CT scans = $200). ($200 + $200 = $400). The CT scans and the PET scan fall 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 copayments for the CT scans and the PET scan provided from April 1, 
2019 to November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (CPT 97032) provided from March 
24, 2020, to April 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
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 the chiropractic services (CPT 97032) provided from March 24, 2020, to 
April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you have spurs on the bottom and sides of your feet
which are very painful. You say that you have been getting cortisone shots for the pain however you can only
get them every three months. You stated that your doctor recommended inserts to help alleviate the pain in
your feet and she thought that the Plan should help pay for them. You say that while the request for coverage
may be unusual, it is necessary for your pain relief. You asked the Plan to reconsider providing coverage for
your foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and ambulance
services provided from January 27, 2020 to February 3, 2020.
You asked the Plan to waive the copayments for an inpatient hospital stay and ambulance services. You say
that you had to be transferred to another facility for a second surgery and feel that you should not have to pay
for the first surgical procedure because now you are worse off. 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 $325
copayment for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you must
pay a $350 copayment for ambulance services.
You received an inpatient hospital stay from January 27, 2020 to February 3, 2020. Therefore, you are
responsible to pay a $325 copayment for days 1-5 (January 27, 2020 to January 31, 2020). $325 (copayment) x
5 (inpatient days) = $1,625.00.
You received ambulance services on February 3, 2020. Therefore, you are responsible to pay the allowed
amount of $283.79, which is less than the $350 copayment.
The total amount you owe is: $1,908.79.
You have been asked to pay the total copayment amount of $1,908.79 for an inpatient hospital stay and
ambulance services. An inpatient hospital stay falls within the inpatient hospital care benefit category.
Ambulance services fall within the ambulance services benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the copayments for an inpatient hospital stay and ambulance services provided from January 27, 2020 to
February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 11, 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 October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 9, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says must 
receive care from a network provider and in most cases, care received from an out-of-network provider will not 
be covered, except for the following: emergency care or urgently needed service and needed medical care that 
Medicare requires our plan to cover and the providers in our network cannot provide this care (authorization is 
required). 
 
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 provided on December 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an insertion of central venous catheter 
provided by a participating provider on December 4, 2019. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you already met your out-
of-pocket maximum. 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 $350 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay $72.02 due to reaching your out-of-pocket maximum with this amount included 
for an outpatient surgery. An outpatient surgery falls within the outpatient surgery/outpatient hospital facility 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an insertion of central venous 
catheter provided by a participating provider on December 4, 2019.