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

 
We decided that the Plan does not have to pay for an office visit provided on March 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast imaging services provided on March 29, 2023. 
 
You asked the Plan to pay for the breast imaging services. You say that you have submitted documentation 
with your appeal. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the breast imaging 
services provided on March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 13, 2022, to December 24, 2022, the inpatient hospital stay provided from February 17, 2023, to 
March 1, 2023, and the emergency room visit provided on February 9, 2023. 
 
You asked the Plan to waive the copayment for the two inpatient hospital stays, and the emergency room visit. 
You say that you think that the cost sharing is too high. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $200 
copayment each time you are admitted to an acute care hospital, and a $110 copayment for each covered 
emergency room visit. 
 
You have been asked to pay a $400 copayment for the two inpatient hospital stays ($200 copayment x 2 stays = 
$400). These items/services fall within the inpatient hospital care benefit category. You have also been asked to 
pay a $110 copayment for the emergency room visit. This item/service falls within the emergency 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 the inpatient hospital stay provided from 
December 13, 2022, to December 24, 2022, the inpatient hospital stay provided from February 17, 2023, to 
March 1, 2023, and the emergency room visit provided on February 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a soft tissue head and neck ultrasound 
provided on March 27, 2023. 
 
You asked the Plan to waive the coinsurance for a soft tissue head and neck ultrasound. You say that you have 
difficulty affording the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for Medicare-covered diagnostic radiology services, including ultrasounds. 
 
You have been asked to pay 20% coinsurance for a soft tissue head and neck ultrasound. This item/service falls 
within the Medicare-covered diagnostic radiology services, including ultrasounds 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. The total you owe is $26.54 ($132.72 
allowed amount x 20% = $26.54). Therefore, we decided that the Plan does not have to waive the coinsurance 
for a soft tissue head and neck ultrasound provided on March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on November 15, 2022. 
 
You asked the Plan to pay for outpatient surgery services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient surgery 
services provided on November 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the endoscopy procedure provided on June 
10, 2022. 
 
You asked the Plan to reduce the copayment for the endoscopy procedure. You say that the copayment is too 
high. The Plan denied your request. The Plan says this cost sharing was charged 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 $100 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $100 copayment for the endoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for the endoscopy procedure provided on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 14, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab testing provided on April 21, 2022. 
 
You asked the Plan to waive the coinsurance for lab testing. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for lab testing. This item/service 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. The total you owe is $406 ($2,030 allowed amount x 20% = $406). Therefore, we decided that the Plan does not have to waive the coinsurance for lab testing provided on 
April 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you live alone and cannot be safely discharged. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 31, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel that this service should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the each covered 
visit or consultation in an outpatient location with a specialist 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 office visit provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bone stimulator provided on April 04, 
2023. 
 
You asked the Plan to waive the coinsurance for a bone stimulator. You say that the item was approved by the 
Plan and should be fully covered. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for a bone stimulator. This item/service falls within the durable 
medical equipment 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. The total you owe is $931.35 ($4,656.73 allowed amount x 20% = 
$931.35). Therefore, we decided that the Plan does not have to waive the coinsurance for a bone stimulator 
provided on April 04, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
December 05, 2022, to December 06, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you say that someone 
should have explained what observation meant in terms of billing. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided on December 05, 2022, to December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on March 28, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that the enrollee did not have any 
input in choosing who would be their provider. The Plan denied your request. The Plan says that unauthorized, 
out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chronic care 
management services provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry visit provided on March 22, 2023. 
 
You asked the Plan to waive the copayment for podiatry visit. You say that you say that it was your 
understanding as long as you had a referral you would be covered. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $45 
copayment for podiatry services. 
 
You have been asked to pay a $45 copayment for podiatry visit. This item/service 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. However, since the allowed amount is less than the standard copayment, you only owe $27.46. Therefore, 
we decided that the Plan does not have to waive the copayment for podiatry visit provided on March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on March 3, 
2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on March 3, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the lumbar spine provided on February 11, 2023. 
 
You asked the Plan to pay for the x-ray of the lumbar spine. You say that you are requesting reconsideration 
due to medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the x-ray of the lumbar 
spine provided on February 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on April 12, 2023. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that this service was a colorectal 
screening and should be fully covered. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $395 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $395 copayment for a colonoscopy. This item/service falls within the in-network 
outpatient surgery, including services provided at hospital outpatient facilities 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. The record shows you had a diagnostic 
colonoscopy. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy 
provided on April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power mobility device provided on February 17, 2023. 
 
You asked the Plan to pay for a power mobility device. You say that you are requesting reconsideration of the 
denied item. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a power mobility device 
provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 29, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. The Plan denied your request. The Plan says that unauthorized, out-
of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 29, 2023.