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

 
We decided that the Plan does not have to pay for Multianalyte Assays with Algorithmic Analyses, the 
DecisionDx-SCC provided on November 16, 2021. 
 
You asked the Plan to pay for the DecisionDx-SCC. You say that the DecisionDx-SCC is medically necessary. 
The Plan denied your request. The Plan says the Multianalyte Assays with Algorithmic Analyses,  
DecisionDx-SCC is not medically necessary. 
 
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 Multianalyte Assays with Algorithmic 
Analyses, DecisionDx-SCC. Our reviewer says that the Multianalyte Assays with Algorithmic Analyses, 
DecisionDx-SCC is not medically necessary. Our physician reviewer found that this assay is not the standard of 
care for predicting metastases of SCC. 
 
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 DecisionDx-SCC have not been met. Therefore, we decided that the Plan 
does not have to pay for Multianalyte Assays with Algorithmic Analyses, the DecisionDx-SCC provided on 
November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
January 13, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that the tech running the 
initial test rushed you in and out of the procedure making you wonder how thorough her x-rays had been. You 
also ask if the diagnostic should be part of the annual exam. 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 $130 
copayment for x-rays, including mammograms at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $82.84, which is less than the $130 copayment for a diagnostic mammogram. A 
diagnostic mammogram 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 diagnostic mammogram 
provided on January 13, 2022.  
 
Your complaint about the tech rushing you in and out of your procedure 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay from August 29, 
2021, to September 2, 2021. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that this claim was from 
being admitted into the hospital when you had COVID-19. 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 15% 
coinsurance for an inpatient hospital stay.  
 
You have been asked to pay $956.82, which is less than 15% coinsurance of the allowed amount for an 
inpatient hospital stay. The record shows you met your MOOP during the processing of this claim. An inpatient 
hospital stay falls within the Inpatient Hospital 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 
coinsurance for an inpatient hospital stay from August 29, 2021, to September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your lab to process, and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering and referring providers are both out-of-network providers and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided 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 laboratory services provided on November 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you saw the out-of-network provider 
the year prior for a consultation and would like to see them again. The Plan denied your request. The Plan says 
they approved an authorization to see the out-of-network provider the year prior for a consultation. The 
documentation received does not indicate the services are urgent or emergent in nature and that the service 
requested can be scheduled with an in-network provider. Also, there are in-network providers that provide the 
same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on December 7, 2021. 
 
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 had network providers available 
who could have provided 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 drug test (G0480) rendered by the out-of-network (OON) provider on December 7, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 23, 2021, to October 7, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 an $80 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay an $400 copayment for 5 days of inpatient hospital care ($80 x 5 = $400). 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 inpatient hospital stay provided from September 23, 
2021, to October 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a regadenoson injection (J2785) provided 
on December 29, 2021. 
 
You asked the Plan to waive the coinsurance for the regadenoson injection. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services 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 20% 
coinsurance for Medicare Part B prescription drugs, and the administration of them.  
 
 
  You have been asked to pay a 20% coinsurance for the regadenoson injection (allowed is $250.74 x 20% = 
$50.15). Regadenoson injections 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 coinsurance for a regadenoson injection (J2785) provided on December 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone; weekly bundle 
including dispensing and/or administration, substance use counseling, individual and group therapy, and 
toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program) 
provided on November 1, 2021, to November 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if 
performed (provision of the services by a Medicare-enrolled opioid treatment program). You say that you do 
not know why, after all this time has gone by, are they denying payment. You also say that you have already 
been receiving services from this provider for about 6 or 7 years, and you do all your treatment there. The Plan 
denied your request. The Plan says these services were provided by an out-of-network provider as the provider is not contracted with the Plan. The Plan also says that there is no documentation that this member was referred 
to this non-contracted provider by a contracted provider, as well as no indication or any attempt made to obtain 
prior authorization for the out-of-network services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 medication assisted treatment, methadone; weekly 
bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and 
toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program) 
provided on November 1, 2021, to November 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you were approved to see a provider 
that you have seen already, and they will not give you Hydrocodone and Acetaminophen for your pain. The 
Plan denied your request. The Plan says these services are available within the contracted 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), the influenza virus vaccine (90686), 
and the immunization administration (90471) rendered by the out-of-network (OON) provider on  
November 15, 2021. 
 
You asked the Plan to pay for this item/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 item/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 had network providers available 
who could have provided the item/services at issue in this appeal. The Plan did not pre-approve the 
item/services at issue. We found no exception that would require the Plan to pay for this item/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99202), the influenza virus 
vaccine (90686), and the immunization administration (90471) rendered by the out-of-network (OON) provider 
on November 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration of the 
authorization requested. The Plan denied your request. The Plan says there are 4 in-network SNF providers that 
are within the time and travel distance that Medicare allows. Also, the service requested is not urgent or 
emergent in nature. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Manual Wheelchair to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Manual Wheelchair. You say that this wheelchair would help you transport 
and be a lot safer when going to his medical appointments. The Plan denied your request. The Plan says the 
requested provider is out-of-network. The Plan also says that the wheelchair has been approved with a 
contracted durable medical equipment 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item at issue and the wheelchair has been approved with a contracted durable 
medical equipment provider. We found no exception that would require the Plan to pre-approve this item. 
Therefore, we decided that the Plan does not have to pre-approve Manual Wheelchair to be provided by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external ocular photography with interpretation and 
report (92285) and the ophthalmological medical examination and evaluation (92014) rendered by the out-of-
network (OON) provider on November 29, 2021. 
 
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 had network providers available 
who could have provided 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 external ocular photography with interpretation and report (92285) and the 
ophthalmological medical examination and evaluation (92014) rendered by the out-of-network (OON) provider 
on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit and diagnostic 
sleep study provided from October 28, 2021, to October 29, 2021. 
 
You asked the Plan to waive the copayment for the office visit and diagnostic sleep study. You say that that 
these services should be covered. The Plan denied your request. The Plan says the copayments 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 $35 
copayment for the diagnostic sleep study and a $50 copayment for the specialist office visit. 
 
You have been asked to pay a total of $85 ($35 copayment for the diagnostic sleep study and a $50 copayment 
for the specialist office visit). The diagnostic sleep study falls within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The office visit falls within the Physician/practitioner 
services, including doctors office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist office visit and diagnostic sleep study provided from October 28, 2021, to October 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan (71250) 
provided on December 13, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services 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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $140.85 copayment for the CT scan, which is less than the standard $150. CT 
scans fall 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 computed tomography (CT) scan (71250) provided on 
December 13, 2021.