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

 
We decided that the Plan does not have to waive the deductible for a specialist office visit and laboratory 
services provided on March 14, 2022. 
 
You asked the Plan to waive the deductible for the specialist visit and lab services. You say that nothing was 
done at this visit. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
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 $500 deductible which applies to certain items and services.  
 
The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. The lab services fall 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 $500 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the specialist visit and lab services were received on March 14, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for a specialist office visit and laboratory services 
provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a back injection provided to the 
enrollee on April 5, 2022. 
 
You asked the Plan to waive or reduce the copayment for the injection. You say that the copayment is too 
expensive. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $370 copayment per day for outpatient procedures and services.  
 
The enrollee has been asked to pay a $370 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 or reduce the copayment for a back injection 
provided to the enrollee on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services provided from February 
11, 2022, to March 30, 2022. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that your dialysis should be 
fully covered by insurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for outpatient dialysis treatments.  
 
You have been asked to pay $58.80 for each treatment visit, which is 20% of the allowed amount for the 
dialysis services ($294.00 allowed amount x 20% coinsurance = $58.80). The file shows 21 visits from 
February 11, 2022, to March 30, 2022. The total for the services is $1,234.80 ($58.80 coinsurance x 21 visits = 
$1,234.80). The dialysis services fall within the Services to Treat Kidney Disease 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 dialysis services provided from February 11, 2022, to March 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ophthalmological service on December 13, 
2021. 
 
You asked the Plan to waive the deductible for ophthalmological service. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 which applies to Vision Care.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Vision 
Care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible 
which applies to Vision Care. This cost sharing is a contractual obligation that had not been met at the time 
ophthalmological service was received on December 13, 2021. Therefore, we decided that the Plan does not 
have to waive the deductible for ophthalmological service on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an EndoFlip procedure. 
 
You asked the Plan to pre-approve an EndoFlip procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an EndoFlip procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while EndoFlip may offer improved assessment of esophageal distensibility and is a 
promising novel technique, its use in lieu of conventional manometry is not standard of care in achalasia 
diagnosis, and as such not medically necessary for you at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EndoFlip procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an EndoFlip procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayments for wound care services performed 
from January 10, 2022, to January 31, 2022. 
 
You asked the Plan to waive or reduce the copayments for the wound care. You say that you do not understand 
the charges for these services. 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 $250 
copayment for each surgery or service provided at an outpatient hospital or ambulatory surgical center.  
 
 You have been asked to pay a $250 copayment for each of the four visits for the wound care. The total for all 
visits is $1,000 ($250 copayment x 4 visits = $1,000). The wound care falls within the Outpatient Surgery, 
Including 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 or reduce the copayments for wound care services performed from 
January 10, 2022, to January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract eye surgery performed on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that you cannot afford the copayment. 
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 $270 
copayment for surgery or services provided at an outpatient hospital.  
 
You have been asked to pay a $270 copayment for the eye surgery. The eye surgery falls within the Outpatient 
Surgery, Including 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 a cataract eye surgery performed on December 
22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on April 13, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing 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 Medicare-covered Part B Chemotherapy drugs and other Part B drugs. These drugs are covered 
under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. 
Covered drugs include drugs that usually arent self-administered by the patient and are injected or infused 
while you are getting physician, hospital outpatient, or ambulatory surgical center services. There were two 
charges. One for $20 and one for $66.79. $20 + $66.79 = $86.79. Therefore, results in the total cost sharing 
amount of $88.79. 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs 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 Part B drugs on 
April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided April 29, 2021. 
 
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 this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. This test is not covered for screening purposes. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81479) provided April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax for foot orthotics (S9999) provided March 24, 2022. 
 
You asked the Plan to pay for the sales tax. You say that this service should be covered. The Plan denied your 
request. The Plan says reimbursement for the orthotics has been issued. Payment for sales tax is not permitted 
under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make any additional payment 
for sales tax. 
 
We looked at the file and Medicare rules. Separate payment is not issued for sales tax. Based on this 
information, we decided that Medicare rules for coverage of the sales tax have not been met. Therefore, we 
decided that the Plan does not have to pay for sales tax for foot orthotics (S9999) provided March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ustekinumab (Stelara) injection 
provided on March 31, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not notified of any 
copayment for the service. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for each Part B drug and administration.  
 
You have been asked to pay $1,422.39, which is 20% of the allowed amount for the injection ($7,111.93 
allowed amount x 20% coinsurance = $1,422.39). The injection 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 an ustekinumab (Stelara) 
injection provided on March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care beginning August 18, 2022. 
 You asked the Plan to pay for inpatient care. You say that you need to remain in the hospital because you are 
not in any condition to be transported. The Plan denied your request. The Plan says you were already stable 
during admission and can be transferred to an in-network facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for post-stabilization care. Our reviewer says 
that post-stabilization care was not medically reasonable and necessary. Our physician reviewer found that the 
treating physician did not document (in the physician notes, on a form, or in an order) at any time that you were 
not stable for transfer. Based on the clinical documentation available in the medical record, you were stable for 
transfer to an in-network facility on August 18, 2022, at 10:12 AM when the Emergency Department 
evaluation was complete and you were admitted for inpatient care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care beginning August 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for WATS 3D Histocytology (88361, 88312, 88305, 88104) testing 
provided March 22, 2021. 
 
You asked the Plan to pay for WATS 3D Histocytology. You say that WATS 3D tissue analysis is standard of 
care and therefore medically necessary. The Plan denied your request. The Plan says that the request does not 
meet Medicare rules because a review of the medical literature and clinical practice guidelines does not support 
the clinical utility of this testing, including computer-assisted immunohistochemistry, to predict cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for WATS 3D Histocytology. Our reviewer says 
that the requested testing is considered medically reasonable and necessary in this case. Our physician reviewer 
found that per American Gastroenterological Association (AGA) Clinical Practice Update 2022 "Tissue 
systems pathology-based prediction assay may be utilized for risk stratification of patients with nondysplastic 
Barrett's esophagus." As such, WATS 3-D assay meets standard of care for enrollee's scenario. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of WATS 3D Histocytology have been met. Therefore, we decided that the Plan 
has to pay for WATS 3D Histocytology (88361, 88312, 88305, 88104) testing provided March 22, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for allergy testing provided on March 18, 
2022. 
 
You asked the Plan to waive the copayment for the allergy testing. You say that you feel the allergy test should 
be covered. 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 for non-radiological diagnostic services.  
 
You have been asked to pay a $20 copayment for the allergy testing. The allergy testing 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 allergy testing provided on March 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a glucose monitoring appointment provide 
on March 23, 2022. 
 
You asked the Plan to waive the copayment for a glucose monitoring appointment. You say that you think you 
are being billed for a second time and that it should be waived. The Plan denied your request. The Plan says the 
copayment applied was 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $50 copayment for a glucose monitoring appointment. A glucose monitoring 
appointment 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 glucose monitoring 
appointment provide on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 10, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not have to pay for this 
scan, because you were asked to repeat another exam. The Plan denied your request. The Plan says the 
copayment applied was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $180 copayment for outpatient diagnostic tests.  
 
The enrollee has been asked to pay a $180 copayment for a CT scan. A CT scan falls 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 a computed tomography (CT) scan provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GTC Hematology Profile provided October 19, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was medically necessary The 
Plan denied your request. The Plan says this test is excluded because it includes the FANCC and BLM genes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the GTC Hematology Profile. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that next generation sequencing (NGS) for the work-up of suspected myelodysplastic 
syndrome (MGS) is indicated for younger patients at risk for genetic syndromes. This enrollee is elderly 
without known family history. NGS for the workup of MGS in his case would not be indicated. The service is 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the GTC Hematology Profile have not been met. Therefore, we decided that the 
Plan does not have to pay for the GTC Hematology Profile provided October 19, 2021.