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

 
We decided that the Plan does not have to waive the copayment for podiatry care on March 08, 2022. 
 
You asked the Plan to waive the copayment for podiatry care. 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 $30 
copayment for each Medicare-covered podiatry services. Covered services include diagnosis and the medical or 
surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs). Routine foot care for 
members with certain medical conditions affecting the lower limbs. 
 
You have been asked to pay a $30 copayment for podiatry care. Podiatry care falls within the Podiatry 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 podiatry care on March 08, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus xT testing provided to the enrollee on January 17, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this testing is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that molecular profiling such as with Tempus is considered a standard of care in locally advanced 
pancreatic cancer. The use is supported by the National Comprehensive Cancer Network (NCCN) Guidelines 
to help guide treatment decision making. The service was reasonable and 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 services have been met. Therefore, we decided that the Plan has to pay for 
Tempus xT testing provided to the enrollee on January 17, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction service (92015) provided on April 25, 2022. 
 
You asked the Plan to pay for the vision care. You say that the services you received on the date of service in 
this case were a result of a recent visit with an eye specialist. You also say that they should be covered. The 
Plan denied your request. The Plan says the refraction service is not covered. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services. The file indicates that the 
exam in this case was medical in nature. Therefore, we decided that the Plan does not have to pay for the 
refraction service (92015) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on April 20, 2022, by an out-
of-network (OON) provider. 
 
 
 You asked the Plan to pay for the domiciliary visit. You say that the enrollee said they had Medicare for 
coverage rather than the Plan insurance. You say this means there was no time to obtain prior approval for 
services. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on April 20, 2022, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on April 18, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the treatment you received was medically 
necessary. You also say that the ambulance service is covered by your plan. The Plan denied your request. The 
Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on April 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency transport ambulance services 
provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for emergency transport ambulance services. You say that this was 
for a car accident. You also say that this was not an emergency nor sickness, and you did not need to go to the 
hospital in an ambulance. The Plan denied your request. The Plan says you were 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 $290 
copayment per date of service regardless of the number of trips for ground ambulance.  
 
 
 
 
 
 You have been asked to pay a $290 copayment for emergency transport ambulance services. Emergency 
transport ambulance services fall within the ambulance 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 emergency transport ambulance services provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the spinal x-rays you received on April 
25, 2022, from a chiropractor. 
 
You asked the Plan to pay for the office visit and the spinal x-rays. You say that your Summary of Benefits 
says that you are covered for x-rays and diagnostic tests. The Plan denied your request. The Plan says it has 
paid for the chiropractic spinal manipulation service you received (code 98941) minus your applicable 
copayment, but the office visit and x-rays are not covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit and the spinal x-rays you received on April 25, 2022, from 
a chiropractor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2022 billed with 
codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, 81351, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 21, 2022 billed with codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, 81351, and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cataract removal surgery, and a 
Keratoplasty (corneal transplant) processing provided on January 26, 2021. 
 
You asked the Plan to waive the coinsurance for cataract removal surgery, and a Keratoplasty (corneal 
transplant). You say that you were never advised of this charge by the doctor's office before your eye surgery. 
The Plan denied your request. The Plan says you were 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 20% 
coinsurance of the total cost for each Medicare-covered outpatient hospital facility or ambulatory surgical 
center visit.  
 You have been asked to pay $113.11 in coinsurance, which is 20% of the allowed amount for cataract removal 
surgery ($565.56 x 20% = $113.11). You have also been asked to pay $104.41, which is less than the 20% 
coinsurance for a keratoplasty (corneal transplant). Cataract removal surgery and a Keratoplasty (corneal 
transplant) fall 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 coinsurance for cataract 
removal surgery, and a Keratoplasty (corneal transplant) processing provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services, medical 
examination and evaluation provided on February 15, 2022. 
 
You asked the Plan to waive the copayment for ophthalmological services, medical examination and 
evaluation. You say that you were supposed to have a routine eye exam but the provider added other services 
onto the bill like an eye refraction and photos and never told you this at the time of the visit. The Plan denied 
your request. The Plan says that the provider confirmed that the appointment was not for a routine eye exam. 
You have age related cataracts with right vitreous degeneration and bilateral peripapillary atrophy that needs 
follow up. 
 
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 $45 
copayment for Vision Care.  
 
You have been asked to pay a $45 copayment for ophthalmological services, medical examination and 
evaluation. The ophthalmological services, medical examination and evaluation falls within the Vision 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 ophthalmological services, 
medical examination and evaluation provided on February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on May 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that your organization regularly complies with all 
administrative requirements for payment.  You said that these services were medically necessary and provided 
in good faith. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 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 x-rays provided on May 27, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on May 20, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were unsatisfied with the 
provider you saw. You state they didn't do anything for you. The Plan denied your request. The Plan says the 
copayment was 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 $15 
copayment for urgently needed services.  
 
You have been asked to pay a $15 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) provided on May 18, 2022. 
 
You asked the Plan to pay for presumptive drug testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this cannot be paid on the same date of service as another presumptive test. 
 
The Plan must follow Medicare rules. Medicare rules say that only one presumptive service may be billed per 
patient, per date of service, regardless of the provider.  
 
We looked at the file and Medicare rules. The record shows that a presumptive service was previously billed 
and paid for this patient and date of service. Based on this information, we decided that Medicare rules for 
coverage of presumptive drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for presumptive drug testing (80307) provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 May 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2017 billed for date of service January 25, 
2022. 
 
You asked the Plan to pay for procedure code H2017. You say that this code is payable by Medicaid. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 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 H2017 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2017 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2017 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2017 billed for date of service January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on February 25, 2022. 
 
You asked the Plan to pay for diagnostic radiology 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 diagnostic radiology services provided on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment provided on April 20, 2021. 
 
You asked the Plan to pay for the medical equipment. You say that your organization was having issues with 
its new system, and you were not aware that this claim was part of this system issue. The Plan denied your 
request. The Plan says you did not timely file your claim initially, and you did not submit a corrected claim 
until May 6, 2022. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
medical equipment was not filed until April 23, 2022. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for medical equipment provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for oxygen equipment on May 08, 2021, to June 08, 
2021. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says that the cost sharing you are being charged 
is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Without the correct Evidence of Coverage (EOC), there is no way of knowing 
whether the coinsurance being charged is correct. Therefore, we decided that the Plan has to waive the 
coinsurance for oxygen equipment on May 08, 2021, to June 08, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on May 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 wound care services provided on May 3, 2022, 
by an out-of-network (OON) provider.