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

We decided that the Plan does not have to pay forthe Guardant360 testing provided on May 19, 2020.You asked the Plan to pay forthe testing services. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee's advancedcancer.The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.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 testing services were not billed with the most comprehensive code.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on January 1, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says there is a more 
appropriate code to describe the services provided. 
 
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 testing was not billed according to the Medicare guidelines. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided on January 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on June 9, 
2020. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that the ultrasound should be fully 
covered because you have dense breast tissue and a family history of breast cancer. 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 $30 
copayment for ultrasounds.  
 
You have been asked to pay a $30 copayment for a breast ultrasound. A breast ultrasound 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 a breast ultrasound provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for problem focused limited oral evaluation (D0140) provided 
on April 14, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were treated for an 
abscessed tooth, which could not be treated otherwise. The Plan denied your request. The Plan says this service 
exceeds the frequency limitation in your benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on January 8, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for problem 
focused limited oral evaluation (D0140) provided on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Nursing Facility Care (99310) provided on September 10, 2019 by an out of network (OON) provider.You asked the Plan to pay forNursing Facility Care. You say that your physician provided medically necessary services to the member in good faith.The Plan denied your request. The Plan says there was no medical necessity for 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 forthe Nursing Facility Care (99310) provided on September 10, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services. 
 
You asked the Plan to waive the copayment for these services. You say that the appointment was cancelled and 
you did not go. The Plan denied your request. The Plan says the copayment was applied 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 $300 
copayment for each Medicare-covered hospital facility visit.  
 
Review of the file shows that you received outpatient hospital services. The file confirms that 
this appointment was rendered and you received services. You have been asked to pay a $300 copayment for 
these services. These services fall within the Medicare-covered hospital facility visit 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 outpatient hospital services rendered.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99344) rendered by the out of network 
(OON) provider on October 16, 2019. 
 
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 the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the home visit (99344) rendered by the out of network (OON) provider on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe personal protective equipment (D1999) provided on June 25, 2020.You asked the Plan to pay forthe personal protective equipment (PPE). You say that you were charged $10 for PPE. You say that you do not feel this charge is fair or valid.The Plan denied your request. The Plan says that personal protective equipment (PPE) is not covered under your dental benefit.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 personal protective equipment is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe personal protective equipment (D1999) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physical therapy evaluation (97161) provided on February 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe physical therapy evaluation. You say that the plan does not require referrals for physical therapy. You confirmed with the enrollee that they have not received physical therapy in any other facility in the last 12 months.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 forthe physical therapy evaluation (97161) provided on February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chiropractic office visit (99201) and anx-ray (72100) provided on March 27, 2020.You asked the Plan to pay fora chiropractic office visit  and an x-ray. You say that this should be covered.The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.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 fora chiropractic office visit (99201) and an x-ray (72100) provided on March 27, 2020
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on December 11, 
2019. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an emergency department visit provided on December 11, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on February 27, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that enclosed is the medical record as 
supporting documentation indicating the need for hospital care and the treatment rendered. You are requesting 
retroactive approval for the stay. The Plan denied your request. The Plan says enrollee's must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 hospital stay provided on February 
27, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear stress test and coinsurance for an 
injection provided by a participating provider on June 1, 2020. 
 
You asked the Plan to waive the copayment for a nuclear stress test and coinsurance for an injection. You say 
that you do not agree with this amount you are being charged. The Plan denied your request. The Plan says the 
correct copayment and coinsurance have 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 for outpatient diagnostic tests/nuclear medicine/freestanding facility and a 20% coinsurance for 
Medicare Part B prescription drugs.  
 
You have been asked to pay a $100 copayment for a nuclear stress test and a 20% coinsurance of the allowed 
amount for an injection. The total allowed amount is $213.73. The total amount you are being asked to pay for 
an injection is $42.75. The total amount you are being asked to pay is $142.75 ($100 + $42.75 = $142.75). An 
injection falls within the Medicare Part B prescription drugs benefit category and a nuclear stress test falls 
within the outpatient diagnostic tests/nuclear medicine/freestanding 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 and coinsurance for an injection and a nuclear stress test provided by a 
participating provider on June 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation on X-ray examination made elsewhere, written 
report (CPT Code 76140) provided on February 25, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this service is not covered under Medicare or the Health Plan. The Plan states if the provider 
determines that a billing error occurred during the initial submission of the denied claim, the Plan would accept 
a submission of a corrected claim to consider services for payment. 
 
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 service have not been met. Medicare guidance says, HCPCS 
code 76140 is assigned a status code = I. Medicare guidance says status code  Not valid for Medicare 
purposes. Medicare uses another code for reporting of and payment for these services. Therefore, we decided 
that the Plan does not have to pay for consultation on X-ray examination made elsewhere, written report (CPT 
Code 76140) provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on February 6, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the laboratory services rendered by the out of network (OON) provider on February 6, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for the physician services. You say that this was a wellness visit 
and therefore there should not be a copayment. The Plan denied your request. The Plan says you received a 
separate additional service so you were charged a copayment 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 $15 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $15 copayment for the physician services, 99213. This physician service falls 
within the Physician/Practitioner services benefit category and is separate from the wellness 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 office visit provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab services you received on March 19, 
2020. 
 
You asked the Plan to waive the deductible for the lab services. You say that these lab services were part of 
your annual physical, so there should be no deductible applied. The Plan denied your request. The Plan says 
you were assessed this deductible correctly. 
 
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 $500 deductible.  
 
Your EOC clearly states that lab services you received during an annual physical exam or wellness visit are not 
part of the exam itself and you may be held responsible for cost sharing for these services. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies to lab 
services. This cost sharing is a contractual obligation that had not been met at the time the lab services were 
received on March 19, 2020. Therefore, we decided that the Plan does not have to waive the deductible for lab 
services you received on March 19, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first pair of post-cataract eyeglasses with a zero 
copayment. We decided that the Plan does not have to pay for the second pair of post-cataract eyeglasses. 
 
You asked the Plan to pay for the two pair of post-cataract eyeglasses. You say that the Plan eyewear benefit is 
coverage is for two pair of eyeglasses after cataract surgery. The Plan denied your request. The Plan says if you 
have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two 
eyeglasses after the second surgery. The Plan says that when out of network, there is a 20% coinsurance for one 
pair of standard Medicare-covered eyeglasses or contact lenses. Progressive lenses, no-line bifocal or trifocal 
lenses, tinting (except for certain ultraviolet-screening coatings), scratch resistant coatings, or oversized lenses 
are not covered unless required by Medicare coverage guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that one pair of conventional eyeglasses or contact lenses 
furnished after each cataract surgery with insertion of an IOL are covered. The contract with the Plan says that 
the Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an 
intraocular lens (If you have two separate cataract operations, you cannot reserve the benefit after the first 
surgery and purchase two eyeglasses after the second surgery.) When you get these services out-of-network 
you must pay a 20% coinsurance for one pair of standard Medicare-covered eyeglasses or contact lenses. 
Progressive lenses, no-line bifocal or trifocal lenses, tinting (except for certain ultraviolet-screening coatings), 
scratch-resistant coatings, or oversized lenses are not covered unless required by Medicare coverage guidelines. 
 
We looked at the file, Medicare?s rules and the Plan's rules. The file shows you purchased two post-cataract 
eyeglasses after the second cataract surgery. The file also shows that the eyewear was provided by a provider 
that is out-of-network and the Plan reprocessed one pair of eyeglasses to pay the standard allowable for lenses 
with 20% out of network coinsurance. Therefore, we decided that the Plan does not have to pay for the first 
pair of post-cataract eyeglasses with a zero copayment and we decided that the Plan does not have to pay for 
the second pair of post-cataract eyeglasses.