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

We decided that the Plan does not have to waive the copayment for the tests provided on March 10, 2020.
You asked the Plan to waive the copayment for the tests. You say that the Plan should pay the claim. The Plan denied your request. The Plan says you were charged this 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 $65 copayment for outpatient diagnostic tests at a network doctor's office. You have been asked to pay $65 copayment for the copayment for the tests. The copayment for the tests 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 tests provided on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT angiogram provided by a participating 
provider on March 3, 2020. 
 
You asked the Plan to waive the copayment for a CT angiogram. You say that you did not have a CT scan. 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 $250 
copayment for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay $192.89 which is less than your copayment amount of $250 for a CT angiogram. 
Since a CT angiogram was performed, the correct copayment has been applied. A CT angiogram 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 a CT angiogram provided by a participating provider on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 28, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 CPT Code Manual definition of the denied codes is: 
 
CPT 81057: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 28, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent transportation services (A0425 and A0428) 
provided on January 23, 2020. 
 
You asked the Plan to pay for the non-emergent transportation services. You say that you would like 
reconsideration because prior authorization was not obtained due to a miscommunication with the Plan. The 
Plan denied your request. The Plan says the member did not meet criteria for the non-emergent transport and he 
was on hospice. 
 
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 non-emergent transportation services (A0425 and A0428) 
provided on January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient services provided on February 4, 2020. 
 
You asked the Plan to pay for the hospital outpatient services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 hospital outpatient services provided on February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound scan of bilateral arms or legs 
(93970) on February 28, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound scan of bilateral arms or legs. You say that you 
should not have to pay a copayment for a required post-surgical procedure. The Plan denied your request. The 
Plan says the correct copayment was 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 $250 
copayment for each covered diagnostic procedure or test at a network outpatient facility.  
 
You have been asked to pay $216.53 for an ultrasound scan of bilateral arms or legs. An ultrasound scan of 
bilateral arms or legs falls within the Outpatient diagnostic tests benefit category. This means that you have 
been asked to pay less than the full 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 scan of bilateral arms or legs (93970) on February 28, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99292) provided on January 12, 2020. 
 
You asked the Plan to pay for critical care. You say that this was billed correctly. The Plan denied your request. 
The Plan says this code is not supported. 
 
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 CPT Code Manual definition of code 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service).  
 
We find that CPT code 99292 is not supported in the medical record. Specifically, this is an add on code. A 
primary service code was not billed for this date of service. Based on this information, we decided that 
Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care (99292) provided on January 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant 360 testing provided June 28, 2019. 
 
You asked the Plan to pay for Guardant 360 testing. You say that Guardant is the only service provider for 
Guardant360. The Plan denied your request. The Plan says the services were not reported with the correct 
codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that Targeted and Comprehensive 
Genomic Profile Next-Generation Sequencing Testing should be reported with codes 81450, 81479 and 81445. 
 
We find that Guardant360 is not supported for payment as billed. Specifically, this service was not billed with 
codes 81450, 81479 or 81445. Based on this information, we decided that Medicare rules for coverage of 
Guardant 360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant 
360 testing provided June 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ultrasound of the breast (76642) 
performed on February 24, 2020, and a biopsy of the breast (19083) performed on March 12, 2020. 
 
You asked the Plan to waive the copayments for an ultrasound of the breast and a biopsy of the breast. You say 
that the copayments are above and beyond what you are able to afford and should be reconsidered since these 
were not elective procedures. The Plan denied your request. The Plan says the correct copayments were 
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 $160 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, and that you must 
pay a $360 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay $440.32, a combination of an $80.32 copayment for an ultrasound of the breast 
and a $360 copayment for a biopsy of the breast. An ultrasound of the breast falls within the Outpatient 
Diagnostic Tests benefit category. This means that you have been asked to pay less than the full amount based 
on your contract with the Plan. A biopsy of the breast falls within the Outpatient Surgery 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 an ultrasound of the breast 
(76642) performed on February 24, 2020, and a biopsy of the breast (19083) performed on March 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45378) 
performed on October 16, 2018. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the provider led you to 
believe this procedure was a screening colonoscopy. The Plan denied your request. The Plan says the correct 
copayment was 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 $150 
copayment for Medicare-covered outpatient surgery services, received in an outpatient hospital setting or 
ambulatory surgical center.  
 
You have been asked to pay a $150 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the Outpatient surgery 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 diagnostic 
colonoscopy (45378) performed on October 16, 2018.  
 
Your complaint about being misinformed by the provider about the classification of the service you received 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851) provided on December 16, 2019. 
 
You asked the Plan to pay for a knee orthosis. You say that this is supported by the records. The Plan denied 
your request. The Plan says the records do not include a physician order for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. Although there is a 
physician order in the file, it is not for the item at issue.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 a knee orthosis (L1851) provided on December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab services (G0482) provided January 31, 2020. 
 
You asked the Plan to pre-approve the lab services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem. 
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pre-approve lab services 
(G0482) provided January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the immunotherapy injections (95117) 
provided on March 11, 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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay a $10.36 copayment for the injections provided at a specialist office visit. This is 
the Plan allowed amount which is less than the applicable copayment. 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 immunotherapy injections (95117) provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lab Services (G0483) provided January 29, 2020. 
 
You asked the Plan to pay for the Lab Services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem. 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for Lab Services (G0483) 
provided January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided on March 11, 2020 to March 12, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not agree with 
these charges. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for outpatient surgery/in-network/outpatient hospital.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $11,473. The total amount you are being asked to pay is $2,294.60 ($11,473 x 20% = 
$2,294.60). An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital 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 an outpatient surgery provided on March 11, 2020 to March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of inlay, onlay, veneer (D2910) provided on March 17, 2020.

You asked the Plan to pay for the re-cement or re-bond of inlay, onlay, veneer (D2910). You say that this was not a cosmetic restoration. You say that you didn't think to call the Plan to get pre-approval. The Plan denied your request. The Plan says the service is not a covered 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of inlay, onlay, veneer (D2910) provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on February 19, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 outpatient hospital services provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided February 4, 2017. 
 
You asked the Plan to pay for subsequent hospital care. You say that you have made every attempt at obtaining 
payment for this claim. You are once again resubmitting documentation in hopes of obtaining payments for this 
service rendered. 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 member?s terminal condition 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 2, 2017. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care (99231) provided February 4, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on April 16, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you believe that this should be 
paid in full. The Plan denied your request. The Plan says the coinsurance you are being charged is correct. 
 
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 each Medicare-covered Part B drug.  
 
The allowed amount for chemotherapy was $12,978.19. You have been asked to pay a coinsurance of 
$1914.57, which is less than 20% of the allowed amount. Chemotherapy falls 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 coinsurance for chemotherapy 
provided on April 16, 2020.