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

We decided that the Plan does not have to waive the deductible for the mammogram provided on March 10,
2020.
You asked the Plan to waive the deductible for the mammogram. You say that you were told there would not
be a charge for additional mammogram. 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. Your
contract with the Plan says that there is a $750 deductible that applies towards mammograms and a $10
copayment after the deductible is met for each basic imaging service (e.g., general x-rays or ultrasound).
The mammogram 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 $750 deductible that applies towards mammograms.
This cost sharing is a contractual obligation that had not been met at the time the mammogram was received on
March 10, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the
mammogram provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for an ultrasound of the heart. We decided that
the Plan does not have to reduce the cost-sharing charges for an ultrasound of the heart.
You asked the Plan to reduce the cost-sharing charges for an ultrasound of the heart. You say that you disagree
with the charges because this was a remote procedure and you should not owe a copayment. The Plan says that
the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for an ultrasound of the heart from $20
to $10.
The plan says that you must pay a $10 copayment for most X-rays and ultrasounds. Therefore, we decided that
the Plan has to reduce the cost-sharing charges for an ultrasound of the heart from $20 to $10.
We also decided that the Plan does not have to reduce the cost-sharing charges for an ultrasound of the
heart.
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 most X-rays and ultrasounds. Therefore, we decided that the Plan does not have to waive the
copayment for an ultrasound of the heart.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee.
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 (Guardant-360 and NEXT-Generation)
requires use of CPT 81479.
The Plan must follow Medicare rules. Medicare rules say that services must be reported with the correct 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic screening testing.
You asked the Plan to pre-approve genetic screening testing. You say that you feel you are a candidate for this
testing because you have had family members pass away from different types of cancer. The Plan denied your
request. The Plan says the denial of authorization for this testing is correct, because there is no documentation
that you have signs or symptoms of cancer so this is not a Medicare-covered benefit.
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 screening testing, is being 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 pre-approve BRCA1 and BRCA2 genetic screening testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy evaluation, the
therapeutic services, and the occupational therapy evaluation provided on January 3, 2020 to January 29, 2020.
You asked the Plan to reduce the copayments for the physical therapy evaluation, the therapeutic services, and
the occupational therapy evaluation. You say that you do not agree with the total copayment amount of $100.
You say the evaluations were minimal and unnecessary. 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 $20
copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy
services. A separate copayment applies to the initial evaluation and any re-evaluations.
You have been asked to pay a $20 copayment for the physical therapy evaluation, a $20 copayment for each
therapeutic service, and a $20 copayment for the occupational therapy evaluation. ($20 x 5 services = $100).
The physical therapy evaluation, the therapeutic services, and the occupational therapy evaluation fall within
the "Outpatient rehabilitation services" benefit category. The medical record shows you received both a
physical therapy and occupational therapy evaluations.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to reduce the copayments for the physical therapy evaluation, the therapeutic services,
and the occupational therapy evaluation provided on January 3, 2020 to January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on February 25, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under
your contractual policy.
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 office visit (99203) provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on February
24, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges
because prostate exams should not have a copayment. 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 $35
copayment for specialist services.
The medical records show that you received specialist services beyond a prostate screening on February 24,
2020. Therefore, you are responsible to pay the $35 copayment.
You have been asked to pay a $35 copayment 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 copayment for specialist services provided on February 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for nonemergency transportation and parking fees provided from
March 9, 2020 through March 11, 2020.
You asked the Plan to pay for the services. You say that you were told that each round trip would count as one,
not each individual trip. The Plan denied your request. The Plan says the records indicate that 12 trips have
already been covered and that this service exceeds the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of twelve (12) trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pay for nonemergency transportation and parking fees provided from
March 9, 2020 through March 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on January 16,
2020.
You asked the Plan to waive the copayment for the laryngoscopy. You say that this was a follow-up visit and
there was never anything said about a surgical procedure. You say you feel this bill is incorrect. 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 $260
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital,
including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $260 copayment for the laryngoscopy. The laryngoscopy falls within the
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers" benefit category. The medical record shows that the laryngoscopy, which is considered a
surgical procedure, was performed on this date of service.
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 laryngoscopy provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on March 25, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the additional $45
charge. 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 $45
copayment for X-rays.
You have been asked to pay a $45 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
an X-ray provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for finger orthosis (L3933) provided on
March 10, 2020.
You asked the Plan to waive the coinsurance for the orthosis. You say that you were not told there would an
extra charge for the splint which did not fit your finger. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received a finger orthosis (L3933) provided on March 10, 2020. You are
asked to pay 20% coinsurance the orthosis. 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 finger
orthosis (L3933) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on February 24, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network
dental services are not covered.
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 services are not among
those covered under this benefit when provided by an out-of-network provider. The plan only covers dental
services when they are provided by a network provider. The requested provider is not in-network with your
plan. Therefore, we decided that the Plan does not have to pay for the dental services you received on February
24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 5,
2020.
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $50 copayment for lab services provided in an outpatient hospital facility
The enrollee has been asked to pay the allowed amount of $12.07, which is less than the $50 copayment for
laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and
supplies 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 laboratory services
provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on July 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. 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. The Plan says that the member's primary care physician did not refer these services.
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 lab tests provided on July 15, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
January 21, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for the copayment because you did not see a doctor and nothing was done during your emergency
room visit. 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 emergency room visit.
You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The medical record shows a history and physical exam were
completed during your emergency room 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 emergency room visit provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for PT/INR testing billed for dates of service January 2, 2020
through January 9, 2020.
You asked the Plan to pay for the PT/INR testing. You say that this was billed in accordance with Medicare
guidelines. The Plan denied your request. The Plan says this code has a frequency limitation of no more than
one unit per 25 days which has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that providers must bill with the correct code to
describe the services rendered. The rules also say that testing with the home PT/INR system should not be done
more than once per week.
In this case, the definition of the code G0249 is Provision of test materials and equipment for home INR
monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous
thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home
and reporting of test results to physician; testing not occurring more frequently than once a week; testing
materials, billing units of service include 4 tests.
As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare.
Evidence was submitted showing that payment for this code was made on December 16, 2019 which would
include payment for four weekly tests. Payment of this code weekly would indicate testing four times per week,
which is not covered by Medicare guidelines. Therefore, we decided that the Plan does not have to pay for
PT/INR testing billed for dates of service January 2, 2020 through January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for walker, folding, wheeled, adjustable or
fixed height (E0143) provided on April 10, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you were told by the provider that the
DME would be free. The Plan denied your request. The Plan says the claim was processed accordingly with
your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received a walker, folding, wheeled, adjustable or fixed height (E0143) on
April 10, 2020. You are asked to pay 20% coinsurance for the walker. Your EOC states, "enrollees must pay
20% coinsurance for DME and related supplies. Covered items include, but are not limited to: wheelchairs,
crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home,
IV infusion pumps, speech generating devices, PAP therapy and oxygen equipment, nebulizers, and walkers."
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 walker, folding, wheeled, adjustable or fixed height
(E0143) provided on April 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on January 15, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you had no choice about where to obtain this x-ray. You say you could have had an x-ray prior to this visit at a facility that insurance covers. 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 $30 copayment for basic radiological services at an in-network specialist's office. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $30 copayment for the x-ray at an in-network specialist's office.
You have been asked to pay a $26.19 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray provided on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax (S9999) applied to the approved surgical
procedure on October 27, 2019.
You asked the Plan to pay for the sales tax (S9999). You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says they have overturned their denial of payment
for the surgical procedure; however, the sales tax is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say contractors do not make any additional payment for sales
taxes.
We looked at the file and Medicare rules. In this case, the Plan has approved payment for the surgical
procedure provided on October 27, 2019. However, Medicare does not make separate payment for sales tax.
Therefore, we decided that the Plan does not have to pay for the sales tax (S9999) applied to the approved
surgical procedure on October 27, 2019.