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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on June 5, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not feel like you 
should have to pay this because the surgeon did nothing to help you after your discharge. The Plan denied your 
request. The Plan says the correct copayment has been applied to the services that were 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was 
provided, the correct copayment has been applied. An emergency room visit falls within the emergency 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 emergency room visit 
provided by a participating provider on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on August 17, 2019. 
 
You asked the Plan to pay for the dental service. You say that you are not pleased with the Plan's process in 
regards to dental reimbursement. You also say that you keep getting denied for reimbursement for the services 
you received in 2019 not being preventive in nature. The Plan denied your request. The Plan says the 
comprehensive periodontal evaluation you received is not a preventive dental service. The Plan also says that 
this service is not a covered service. 
 
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 dental service you received is not 
among those covered under this benefit as it is not a preventive dental service. Therefore, we decided that the 
Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on August 17, 2019.  
 
Your complaint about dissatisfaction with the dental reimbursement process is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for telehealth services. You say that this was follow-up 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. The Plan says that these services could have been provided in-network. 
 
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 telehealth services provided on January 15, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe positron emission tomography (PET) with computed tomography (CT) of skull base to thigh (78815) services provided on January 7, 2020 byan out of network (OON) provider.You asked the Plan to pay forPET image with CT of skull to thigh. You say that the services rendered were medically necessary.The Plan denied your request. The Plan says there was no medical necessity for an out-of-network provider with no referral or prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 positron emission tomography (PET) with computed tomography (CT) of skull base to thigh (78815) services provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cerebral perfusion analysis (0042T) provided February 23, 
2020. 
 
You asked the Plan to pay for the Cerebral perfusion analysis. You say that the service was medically 
necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
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 CPT code 0042T is not supported in the medical record. Specifically, per Local Coverage Article: 
Billing and Coding: Services That Are Not Reasonable and Necessary (A56967), CPT code 0042T is not 
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the Cerebral 
perfusion analysis have not been met. Therefore, we decided that the Plan does not have to pay for Cerebral 
perfusion analysis (0042T) provided February 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from April 9, 2020, through April 15, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request. 
The Plan says that the copayment 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 $200 
copayment per day for days 1-5 of Inpatient hospital care.  
 
You have been asked to pay a $400 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the days 1-5 of Inpatient hospital care benefit category. This means that you have been 
asked to pay less than 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 from April 9, 2020, through 
April 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on March 25, 2020.You asked the Plan to waive the copayment foremergency care. You say that you disagree with the charges because you did not receive an infusion and were only in the emergency room for an X-ray.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules saya 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 foremergency care provided on March 25, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on June 
1, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you went to be retested 
for COVID-19. 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 $60 
copayment for urgently needed services.  
 
You have been asked to pay a $60 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
urgently needed services provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant-at-surgery services provided on December 8, 
2019. 
 
You asked the Plan to pay for the assistant-at-surgery services. You say that the services were ordered by the 
Plan's in-network physician. The Plan denied your request. The Plan says the provider is not recognized for 
payment per CMS guidelines. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant-at-surgery services 
provided on December 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and oxygen 
provided from February 6, 2020, through March 6, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you should not be responsible for 
these charges. The Plan denied your request. The Plan says that there is a 20% coinsurance for these items. 
 
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% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for these services. These services fall within the Durable 
medical equipment (DME) and related 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 
coinsurance for the oxygen concentrator and oxygen provided from February 6, 2020, through March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided by a participating 
provider on February 7, 2020. 
 
You asked the Plan to waive the copayment for an EKG. 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 $170 
copayment for outpatient diagnostic tests/diagnostic test outpatient facility.  
 
You have been asked to pay $146.26 which is less than your copayment amount of $170 for an EKG. An EKG 
falls within the outpatient diagnostic tests/diagnostic test outpatient facility benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an EKG provided by a participating provider on February 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on May 12, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on May 12, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy and biopsy service 
(45380) provided on April 22, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $325 
copayment for a surgical service provided at an in-network outpatient facility.  
 
You have been asked to pay a $325 copayment for the diagnostic colonoscopy service provided at an  
in-network outpatient hospital facility. If you have symptoms for which your doctor thinks it is necessary to 
perform a colonoscopy for medical reasons, this is not considered a screening colonoscopy and outpatient 
surgery copays will apply. 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 colonoscopy and 
biopsy service (45380) provided on April 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on  June 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you needed assistance to get back up from 
falling off the toilet. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 4, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the destruction by neurolytic agent 
provided on January 10, 2020, and January 28, 2020. 
 
You asked the Plan to waive the copayment for the destruction by neurolytic agent. You say that you thought 
that you would only owe one $395 copayment, not four separate copayments. 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 $395 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a $395 copayment for the destruction by neurolytic agent. The destruction by 
neurolytic agent falls within the outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 destruction by neurolytic agent provided on January 10, 2020, and January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forestablished patient domiciliary, rest home visit (99335) provided on August 15, 2019 by an out of network (OON) provider.You asked the Plan to pay fordomiciliary, rest home visit. You say that the rendering physician is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain proper authorization from insurance companies.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 forestablished patient domiciliary, rest home visit (99335) provided on August 15, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant 360 testing provided on July 22, 2019.You asked the Plan to pay forthe Guardant 360 testing.You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 81479 is the only code available for billing. Based on this information, wedecided that Medicare rules for coverage of the Guardant 360 testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant 360 testing provided on July 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating provider on March 12, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you did not have to 
pay this much when you had this procedure done in the past and polyps were removed. 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 $225 
copayment for outpatient hospital services/in-network.  
 
You have been asked to pay a $225 copayment for outpatient hospital services. The correct copayment has 
been applied to the services that were provided. Outpatient hospital services fall within the outpatient hospital 
services/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 outpatient hospital 
services provided by a participating provider on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Part B drugs you received on June 15, 
2020. 
 
You asked the Plan to waive the copayment. You say that you did not have to pay this much before. The Plan 
denied your request. The Plan says you are responsible for the cost share. 
 
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% 
coinsurance for Medicare Part B prescription drugs.  
 
Review of the file shows that you were provided Part B drugs on June 15, 2020. The drugs were allowed at 
$1,160.40. You have been asked to pay a 20% coinsurance for the services, totaling $232.08. The services fall 
within the Medicare Part B prescription drugs 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 Part B drugs you received on June 15, 2020.