Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for specialist services provided. 
 
You asked the Plan to waive the coinsurance for specialist services. You say that you disagree with 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 40% 
coinsurance for out-of-network physician/practitioner services, including doctor's office visits.  
 
You received specialist services from an out-of-network provider. 
Therefore, you are responsible to pay your share of the out-of-network charges.  
 
 
Date of Service Service Codes  Allowed Amount Amount You Owe 
8/28/2019 99205, 82962 $215.72 $86.29 
9/12/2019 99214, G0506, 93000 $332.45 $107.26 
9/16/2019 99211, 95251 $60.30 $24.12 
10/24/2019 99214, 82962 $115.04 $46.01 
 
The total amount you owe is: $263.68.  
 
 
You have been asked to pay the total coinsurance amount of $263.68 for specialist services. Specialist services 
fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 27, 2020.

You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 Guardant360 testing is not supported in the medical record. Specifically, this service should be coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fornew patient outpatient office visit (99203) chest x-ray (71046) and Albuterol nebulizer treatment (J7620) provided January 6, 2020.You asked the Plan to waive the copayment forthe urgent care services. You say that please reconsider the patient cost share amount applied to the claim as the diagnosis indicates it is COVID-19 related.The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Planclearly says that you must pay 10% coinsurance for each Part B drug, 10% coinsurance for each Medicare covered standard x-ray and $35 copayment for each urgently needed services visit. You have been asked to pay $38.40 for the urgent care services. The plan applied $35 urgent care copay, $3.39 coinsurance for the chest x-ray and $0.01 coinsurance for the albuterol treatment. The urgent care services fall within the Medicare Part B Prescription Drugs, Outpatient diagnostic tests and therapeutic services and supplies and Urgently needed services benefit categories. 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 fornew patient outpatient office visit (99203) chest x-ray (71046) and Albuterol nebulizer treatment (J7620) provided January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an elevator lift. 
 
You asked the Plan to pre-approve an elevator lift. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says changes or improvements to real property such as the elevator lift 
to be installed outside your home is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 An Elevator lift installed outside your home is not covered under your Health Plan benefits. Changes or 
improvements to real property such as the elevator lift to be installed outside your home is not covered. The 
item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to 
the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that 
the Plan does not have to pre-approve an elevator lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
January 29, 2020 to February 3, 2020 
 
You asked the Plan to waive the copayment for the inpatient services. You say that you want 02/02/2020 and 
02/03/2020 waived. You don't feel you should pay for those 2 days because the social worker convinced you to 
stay after being denied discharge to the rehabilitation facility. The Plan denied your request. The Plan says this 
claim processed with the correct copayment applied per the plan benefits 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $315 
copayment each day for days 1-5 for Inpatient hospital care.  
 
You have been asked to pay $1575 ($315 x 5 days) for the inpatient services. The inpatient services fall within 
the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital services provided January 29, 2020 to February 3, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stocking/sleeve, not otherwise 
specified (CPT Code A6549 x1). 
 
You asked the Plan to pre-approve the stocking. You say that you are status post lumpectomy and have been 
wearing a compression sleeve for the left arm for approximately 10-11 years. You state the compression sleeve  
you used in the past was approved by a previous health plan. The Plan denied your request. The Plan says this 
item is not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the stocking have not been met. The rules say that the following 
are examples of wound care items which are non-covered under the surgical dressing benefit because they do 
not meet the statutory definition of a dressing (not all-inclusive): The following are examples of wound care 
items which are non-covered under the surgical dressing benefit because they do not meet the statutory 
definition of a dressing (not all-inclusive). Therefore, we decided that the Plan does not have to pre-approve 
gradient compression stocking/sleeve, not otherwise specified (CPT Code A6549 x1).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for specialist services provided by a 
participating provider on May 13, 2020. 
 
You asked the Plan to waive the deductible for specialist services. You say that this was a work related injury 
that caused these services. The Plan denied your request. The Plan says the correct deductible 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 $1,500 deductible for physician/practitioner services/specialist.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services/specialist. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1,500 deductible for physician/practitioner services/specialist. This cost sharing is a 
contractual obligation that had not been met at the time specialist services was received on May 13, 2020. The 
total amount you are being asked to pay is $189.37. Therefore, we decided that the Plan does not have to waive 
the deductible for specialist services provided by a participating provider on May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from March 27, 2020, to April 
1, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that a 
location 40+ miles away would be open on Monday that you could go to. You say that you called back and 
were advised that you could go out of network and be reimbursed for the services. You also say that since you 
could not go to the hospital for teeth and under the COVID-19 circumstances, you could go to a dentist that 
was out of network. The Plan denied your request. The Plan says the dental provider in this case is not a 
network provider. The Plan says dental services that you receive out of network are not covered. The Plan also 
says that you were not advised that you could got out of network and receive reimbursement for the services. 
 
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 are not covered when you receive them out of network. Therefore, we 
decided that the Plan does not have to pay for the dental services provided from March 27, 2020, to April 1, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) services performed by a qualified physical 
therapist in the home health or hospice setting, each 15 minutes (G0151). 
 
You asked the Plan to pre-approve the services. You say that you need physical therapy to improve your 
balance, strength and range of motion due to your leg amputation The Plan denied your request. The Plan says 
the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our physician reviewer 
found the requested additional therapy is not generally accepted as specific and effective therapy for your 
condition. You have had extensive therapy for this condition and it does not appear that your functional level 
requires the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. 
You have had prior therapy and have been taught an independent exercise program. The specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain your current condition or to prevent or slow further deterioration. 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve seven (7) services performed by a qualified physical therapist in the home health or 
hospice setting, each 15 minutes (G0151).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CV risk assessment testing provided on May 1, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels is 
denied, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or 
documented CV disease because panel testing is not specific to a given patients lipid abnormality or disease.  
 
We looked at the file and Medicare rules. The requested CV risk assessment testing is non-covered per L36523. 
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 the CV risk assessment testing provided on May 1, 
2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on June 2, 2020.You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Planauthorizes use of out-of-network providers.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 reimburse you 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 hearing aids.We found no exception that would require the Plan to reimburse you for this item. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee suffers from neurogenic 
bowel and has chronic diarrhea. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that the item is 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria is 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 pre-approve a group 1 standard power operated 
vehicle. Our reviewer says that the item is not medically necessary. Our physician reviewer found the 
documentation does not reveal that you have a personal mobility deficit that impairs participation in mobility-
related activities of daily living (MRADLs) in the home. The documentation does not reveal why your mobility 
deficit is unable to be helped by a walker, cane, or manual wheelchair. There is no objective gait or 
neuromuscular exam. The documentation is not clear that you can safely maneuver the power operated vehicle 
in the home or that the requested power operated vehicle group 1 will significantly improve activities of daily 
living (ADL) performance in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation provided on July 9, 2020. 
 
You asked the Plan to pay for the dental service. You say that you had an emergency. You say that you heard 
from someone that this dentist accepted Medicaid. You say that you were not told if they accepted your plan. 
You say that you were not advised the dentist was not in network, nor were you directed back to the plan to 
find someone in network. The Plan denied your request. The Plan says the provider in this case is not a network 
provider. The Plan also says that authorization was not obtained prior to receiving the services. 
 
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 you receive the service out of network. Therefore, we decided that the 
Plan does not have to pay for the sedation provided on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 pre-approve a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the device is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from October 10, 2019, 
through November 22, 2019. 
 
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the stay is not 
medically necessary. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You received skilled nursing level of care from October 10, 2019, through November 22, 2019. The contract 
states that a $170.50 copayment per day applies for SNF services rendered on days 21-100 of a benefit period. 
This copayment is a contractual obligation that you agreed to pay upon enrolling with the Plan and cannot be 
waived or reduced. As medical records substantiate that SNF services were rendered by for a total of 44 days, 
we have determined that no copayment applies for days 1-20 of your SNF benefit period, but that you will 
remain liable for $3,921.50 which is $170.50 per day for days 21-43 of the SNF benefit period. Please note, no 
copayment was assessed for the day of discharge. 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 
SNF care provided from October 10, 2019, through November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiology services provided on June 
30, 2020. 
 
You asked the Plan to waive the coinsurance for the radiology services. You say that the service was covered 
so you did not think there would be coinsurance. The Plan denied your request. The Plan says you were 
charged the coinsurance 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 20% 
coinsurance for Outpatient hospital services, Diagnostic Imaging.  
 
You have been asked to pay 20% coinsurance for the radiology services. The radiology services fall within the 
Outpatient hospital services, Diagnostic Imaging 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 the radiology services provided on June 30, 2020.