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

 
We decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on March 4, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid at the fee schedule rate for 
procedure code 81479. The Plan denied your request. The Plan says the provider relied solely on the results of 
this testing to make a decision regarding drug treatment of uncomplicated depression. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the records provided, there is no documentation of this patient having not responded to at 
least one other medication which is noted in the record as well as being on multiple medications for her 
condition which increase the risk of adverse effects. Additionally, the ordering psychiatrist must be board 
certified in psychiatry or neuropsychiatry. The ordering physician for this test is not boarded in psychiatry or 
neuropsychiatry. Utilizing the information from Medicare LCD L38394, this patient does not meet the criteria 
for GeneSight Psychotropic Assay and is not considered medically necessary and reasonable in the treatment of this individual. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight test provided to the enrollee on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection on March 28, 2022. 
 
You asked the Plan to waive the coinsurance for injection. 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 covered Medicare Part B drugs, including chemotherapy. 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 centers services. The provider billed in the 
amount of $1,260.44 and the allowed amount is $1,046.28. $1,046.28 x 20% = $209.26. Therefore, results in 
the total cost sharing amount of $209.26. 
 
 
 You have been asked to pay a 20% coinsurance for injection. 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 injection on March 
28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on October 1, 2021. 
 
You asked the Plan to pay for the durable medical equipment. 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. 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 proof of delivery for the supplies provided in this case. 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 the durable medical equipment provided on October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on February 24, 
2022. 
 
You asked the Plan to pay for the continuous glucose monitor. 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. 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 proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. 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 the 
continuous glucose monitor provided on February 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 1, 2022.  
You asked the Plan to pay for home health services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a corrected claim form is required. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was not filed with the required CMS-1500 form. A corrected claim was requested and none was received. 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from January 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Watchmen device placement. 
 
You asked the Plan to pre-approve Watchmen device placement. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met.  
The Plan follows Medicare rules. Medicare rules say that CMS covers percutaneous LAAC for non-valvular 
atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the certain conditions. 
 
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 Watchmen device placement. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found guidelines would not 
support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered 
reasonable or medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Watchmen device placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Watchmen device placement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for orthopedic supports provided on April 1, 
2022. 
 
You asked the Plan to waive the coinsurance for orthopedic supports. You say that you should not have to pay 
this coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$1431.57, resulting in a coinsurance amount of $286.30 ($1431.57 x 20% = $286.30) 
 
You have been asked to pay a 20% coinsurance for orthopedic supports. Orthopedic supports 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 orthopedic supports provided on April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided on January 
10, 2022, to April 10, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you never had to pay this in 
the past and you cannot afford the coinsurance. The Plan denied your request. The Plan says the coinsurance 
applied 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 20% 
coinsurance for covered items and related supplies.  
 
 
 
 
 You have been asked to pay $140.84 which is 20% of the allowed amount for oxygen equipment. The allowed 
amount is $704.20 (20% x $704.20= $140.84). Oxygen equipment falls 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 oxygen 
equipment provided on January 10, 2022, to April 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy on March 08, 2022, to 
March 24, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. You say that you were not aware of the 
copay per visit. 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 $35 
copayment for each Medicare-covered physical therapy visit. Covered services include physical therapy, 
occupational therapy, and speech language therapy. There were 6 visits, resulting in the amount of $210. $35 x 
6 = $210. Therefore, results in the total cost sharing amount of $210.  
 
 
 
 
 You have been asked to pay a $35 copayment for physical therapy. Physical therapy falls within the Outpatient 
rehabilitation 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 copayments for physical 
therapy on March 08, 2022, to March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paragard Intrauterine Copper intrauterine device (IUD). 
 
You asked the Plan to pre-approve Paragard Intrauterine Copper IUD. You say that the service is necessary. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-
approve Paragard Intrauterine Copper intrauterine device (IUD).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network mental health visit provided 
on April 7, 2022. 
 
You asked the Plan to waive the copayment for an in-network mental health visit. You say that you should not 
have this copayment. 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 $40 
copayment for outpatient mental health care.  
 
You have been asked to pay a $40 copayment for an in-network mental health visit. An in-network mental 
health visit falls within the Outpatient Mental Health 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 in-network mental health visit provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lab provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for a lab. You say that you should not have to pay this copayment. 
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 $10 
copayment for outpatient diagnostic tests and therapeutic services.  
 
You have been asked to pay a $10 copayment for a lab. A lab falls within the Outpatient Diagnostic Tests And 
Therapeutic 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 a lab 
provided on April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walker provided on April 1, 2022. 
 
You asked the Plan to waive the coinsurance for a walker. You say that you should not have to pay this 
coinsurance. The Plan denied your request. The Plan says the coinsurance that was 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this drug is 
$89.85, resulting in a coinsurance amount of $17.97 ($89.85 x 20% = $17.97). 
 
You have been asked to pay a $17.97 coinsurance for a walker. A walker falls 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 a walker provided on April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgical procedure to repair your brow 
defect provided on March 11, 2022. 
 
You asked the Plan to waive the copayment for the outpatient procedure. You say that you called before the 
surgery and were told it was covered, you want this bill to be waived. 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 outpatient procedures and services.  
 
You have been asked to pay a $250 copayment for the outpatient procedure. The outpatient procedure 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 the surgical 
procedure to repair your brow defect provided on March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stress test provided on April 1, 2022. 
 
You asked the Plan to waive the copayment for a stress test. You say that you should only be charged $15 
copayment like the x-rays. The Plan denied your request. The stress test received is not a standard x-ray. The 
Plan says the copayment applied 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 $75 
copayment per visit for Medicare-covered diagnostic radiology services such as MRI, CT, and PET scans (not 
including X-rays).  
 
You have been asked to pay $75 copayment for a stress test. Stress tests 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 a stress test provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 5, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have to pay this 
copayment because the scheduler did not make the appointment on the correct day, and you had to come back a 
second time. 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 $20 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay a $20 copayment for a specialist visit. A specialist 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 a specialist visit provided on April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hospital bed provided on February 14, 
2022. 
 
You asked the Plan to waive the coinsurance for a hospital bed. You say that you were previously paying less 
for your hospital bed. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare-covered durable medical equipment and related supplies. The resulting charges have 
increased from previous claims because the cost of the service has increased. The allowed amount of the claim 
is $70.52, resulting in a coinsurance amount of $14.10 ($70.52 x 20%). 
 
You have been asked to pay $14.10 for a hospital bed. A hospital bed falls 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 a hospital bed provided on February 14, 2022.