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

 
We decided that the Plan does not have to pay for genetic screening testing provided on April 28, 2020. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this testing is not a 
covered benefit for the diagnoses listed and was performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
genetic screening testing provided on April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health services provided on April 28, 
2020, to May 1, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for inpatient behavioral health services. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services provided by an out-of-network provider. 
 
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 inpatient behavioral health services provided 
on April 28, 2020, to May 1, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from May 11, 
2020, to May 21, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the service should be 
covered in full. 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 $345 
copayment for days 1-4 for inpatient hospital care.  
 
You had an inpatient hospital stay from May 11, 2020 to May 21, 2020. Therefore, you are responsible to pay a 
$345 copayment for days 1-4 (May 11, 2020, to May 14, 2020). $345 (copayment) x 4 (inpatient days) = 
$1,380.  
 
You have been asked to pay the total copayment amount of $1,380 for an inpatient hospital stay. An inpatient 
hospital stay falls 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 an inpatient hospital stay from May 11, 2020, to May 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services (A0427, A0425) 
provided on May 12, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be charged 
because you had no other way to get to the hospital. 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). Your contract with the Plan clearly says that you must pay a $265 
copayment for each date of service of ground ambulance services.  
 
You have been asked to pay a $265 copayment for ambulance 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 ambulance services (A0427, A0425) provided on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on February 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
testing provided on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 21, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. 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 Guardant360 testing provided on March 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99213). You say that you would like reconsideration because you 
were not aware that prior authorization was needed. The Plan denied your request. The Plan says the facility 
did not obtain 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 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 January 24, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on June 4, 2020, to June 7, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this copayment. 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 $100 
copayment per day for days 1-4. There is a $0 copayment for days 5-90. for inpatient hospital care/in-network.  
 
You have been asked to pay a $100 copayment per day for days 1-3 for an inpatient hospital stay. The total 
amount you are being asked to pay is $300 ($100 x 3 days = $300). An inpatient hospital stay falls within the 
inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay provided by a participating provider on June 4, 2020, to June 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 24, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. 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 Guardant360 testing provided on March 24, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing home health visits (G0299) provided 
March 2, 2020 through March 27, 2020. 
 
You asked the Plan to pay for the skilled nursing home health visits. You say that the HIPPS code is 
automatically generated in your computer EHR from what the nurse enters in the OASIS. This is the same 
process that you use for Medicare billing on your home health claims. The Plan denied your request. The Plan 
says a valid HIPPS code required for processing. 
 
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, the submitted HIPPS code 1CFK5 is not valid and effective from January 1, 2008 to December 31, 
2019. Based on this information, we decided that Medicare rules for coverage of the skilled nursing home 
health visits have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
home health visits (G0299) provided March 2, 2020 through March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided to the enrollee on May 29, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided to the enrollee on May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 21, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service March 21, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
(90792) provided on January 24, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation with medical services. You say that medically 
necessary services were rendered in good faith. The Plan denied your request. The Plan says prior authorization 
must be obtained for services rendered by an out-of-network provider. 
 
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 psychiatric diagnostic evaluation with medical 
services (90792) provided on January 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (85025, 36415) provided on April 21, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 laboratory services (85025, 36415) provided 
on April 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist visit provided on February 18, 
2020. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that you do not understand how you 
could be referred to an out-of-network provider. 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. Your 
contract with the Plan says that there is a $950 deductible for out-of-network physician/practitioner services, 
including doctor's office visits.  
 
You had a specialist visit with an out-of-network provider on February 18, 2020. The record shows that you 
had paid $0 toward the $950 deductible prior to receiving the services. Therefore, you are responsible to pay 
the allowed amount of $169.34.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor?s office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $950 deductible for out-of-network physician/practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time a specialist visit was received on February 18, 2020. Therefore, we decided that the Plan does not have 
to waive the deductible for a specialist visit provided on February 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance services and outpatient hospital 
observation provided from March 4, 2020, to March 6, 2020. 
 
You asked the Plan to waive the copayments for ambulance services and outpatient hospital observation. You 
say that you disagree with the charges because you did not have control over the ambulance, and you feel that 
the hospital services were emergent. 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 $240 
copayment for ambulance services. Your contract with the Plan also clearly says that you must pay a $250 
copayment for outpatient hospital observation. 
 
You received ambulance services on March 4, 2020. Therefore, you are responsible to pay the $240 
copayment.  
 
You received outpatient hospital observation from March 4, 2020, to March 6, 2020. Therefore, you are 
responsible to pay the $250 copayment. Please note, observation charges are in your financial favor.  
 
The total amount you owe is: $490.   
 
 
 
 
You have been asked to pay the total copayment amount of $490 for ambulance services and outpatient 
hospital observation. Ambulance services fall within the ambulance services benefit category. Outpatient 
hospital observation falls within the outpatient hospital observation 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 ambulance services and outpatient hospital observation provided from March 4, 
2020, to March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on December 6, 
2019. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the records do not include any indication 
that the brace was necessary or evidence of who completed the exam. 
 
The Plan must follow Medicare rules. The rules state to consider coverage and payment for any item or service, 
the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's 
medical documentation and confirm that Medicare coverage criteria have been met. 
 
The record does not include sufficient information to determine if coverage criteria have been met. Of note, the 
documentation submitted does not include a legible physician signature or evidence that a back brace was 
necessary or requested by the member. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for lumbar-
sacral orthosis (L0650) provided on December 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportation services 
(A0427, A0429) provided from October 11, 2019, to January 26, 2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services 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 $265 
copayment per date of service, regardless of the number of trips for in-network, emergent and non-emergent 
ground ambulance services.  
 
You have been asked to pay $795 ($265 copayment x 3 dates of service) for the ground ambulance services 
provided. 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 ambulance transportation services  
(A0427, A0429) provided from October 11, 2019, to January 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on March 10, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have never had a copayment 
for this before. 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 $110 
copayment for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay a $110 copayment for an ultrasound. The correct copayment has been applied to 
the ultrasound that was provided. An ultrasound falls within the outpatient diagnostic tests/other outpatient 
diagnostic 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 an ultrasound provided by 
a participating provider on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99309) provided on April 15, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 nursing facility care (99309) provided on April 
15, 2020 by an out of network (OON) provider.