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

 
We decided that the Plan does not have to pay for hemoglobin, glycosylated (A1C) testing and a general health 
panel provided to the enrollee on January 13, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare guidance states screening tests without a valid medical diagnosis related to the 
health of the patient are not a benefit. 
 
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 the tests at issue are not a Medicare benefit for the diagnoses listed on the claim. This is being done 
for screening purposes. Medicare guidance states screening tests without a valid medical diagnosis related to 
the health of the patient are not a benefit. 
 
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 hemoglobin, glycosylated (A1C) testing and a general health panel provided to the enrollee on 
January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Select MDx testing provided to the enrollee on March 11, 
2022. 
 
You asked the Plan to pay for to pay for. You say that this was medically necessary. The Plan denied your 
request. The Plan says prior approval was not obtained for this experimental and investigational test. 
 
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 to pay for. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that SelectMDx is a urine-based test which helps determine the risk of aggressive prostate cancer, and 
whether a biopsy may be necessary. HOXC6 and DLX1 testing like the Select MDX test is investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of to pay for have not been met. Therefore, we decided that the Plan does not have 
to pay for Select MDx testing provided to the enrollee on March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on September 29, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you were told to come in for the x-ray 
and you feel it was unnecessary so it should be covered. The Plan denied your request. 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 $35 
copayment for each Medicare covered x-ray.  
 
You have been asked to pay $35 copayment for an x-ray. X-rays 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 an x-ray provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lab provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for a lab. You say that you had this done at the same time as your 
annual, therefore 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 and supplies.  
 
You have been asked to pay a $10 copayment for a lab. A lab 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 
lab provided on April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be charged for an 
office visit since you feel you did not go beyond services included in an annual wellness visit. You say that you 
were disappointed at the service you received. The Plan denied your request. The Plan says services to address 
a medical condition were received and 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 each covered visit or consultation in an outpatient location with your PCP or other primary care 
provider. The medical records show that services that address a medical condition were performed during this 
visit, which is beyond services included in an annual wellness visit. You have been asked to pay a $10 copayment for an office visit. An 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 an office visit provided on April 8, 2022.  
 
Your complaint about your disappointment with your physician 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on 
October 08, 2021, November 24, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment per day for days 1-20 and a $184 copayment per day for days 21-100 for skilled 
nursing facility (SNF) care. For services from October 08, 2021, to October 31, 2021, for a total of 22 days. 
The first 20 day were covered and had 2 days at $184 copayment. $184 x 2 = $368. For services from 
November 01, 2021, to November 24, 2021, for a total of 23 days. $184 x 23 = $4,232. However, the out-of-
pocket was met resulting in a smaller amount. Therefore, results in the total cost sharing amount of $2,472.28.   
 
The enrollee has been asked to pay a $184 copayment for days 21-100 of skilled nursing facility (SNF) care. 
Skilled nursing facility (SNF) care falls within the skilled nursing facility (SNF) care benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on October 08, 2021, 
November 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 16, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you left the ER without being seen 
and went to a different hospital. 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 $90 
copayment for emergency room visits.  
 
The file shows that you were evaluated by the ER staff on April 16, 2022. Therefore, you have been asked to 
pay a $90 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit provided on April 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
provided to the enrollee on March 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99285-AQ (1 Unit) remains not supported, as the 
medical records submitted do not support a comprehensive examination and medical decision making of high 
complexity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function."  
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented to the 
emergency department with generalized weakness. This emergency department evaluation and management 
code requires a comprehensive history, a comprehensive examination and medical decision making of high 
complexity. However, the medical records submitted do not support a comprehensive examination and medical 
decision making of high complexity. The presenting problems were not high severity, posing an immediate 
significant threat to life or physiological function. The review has determined that the records did not support 
the level of care represented by CPT 99285. 
 
We looked at this coder'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 emergency department services (procedure code 99285) provided to the enrollee on March 3, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on 
December 09, 2021, to January 01, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) 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 $0 per 
day for days 1-20, a $184 copayment per day for days 21-62 for each skilled nursing facility (SNF) stay. You 
are covered for up to 100 days per benefit period. A prior hospital stay is not required. We will only cover your 
stay if you meet certain Medicare guidelines, and your stay is medically necessary. There were 3 days in total. 
$184 x 3 = $552. Therefore, results in the total cost sharing amount of $552.  
 
 You have been asked to pay a $184 copayment per day for days 21-62 of skilled nursing facility (SNF) care. 
Skilled nursing facility (SNF) care falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care on December 09, 2021, to 
January 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the 
enrollee from March 11, 2022, to March 19, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that this stay should be included 
with a previous stay for the same condition. The Plan denied your request. The Plan says the enrollee was 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $225 per day for days 1-7 and $0 per day for days 8-90 for each inpatient admission.  
 
The file shows that the enrollee was in the hospital from March 11, 2022, to March 19, 2022. Therefore, the 
enrollee was asked to pay $225 per day for days 1-7 of inpatient care. The total for the stay is $1,575 ($225 
copayment x 7 days = $1,575). The inpatient care falls within the Inpatient Hospital Care benefit category. This 
means that the enrollee was asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from 
March 11, 2022, to March 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LinQ sacroiliac (SI) joint stabilization system. 
 
You asked the Plan to pre-approve LinQ SI joint stabilization system. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve LinQ SI joint stabilization system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows the requested LinQ to be an effective and/or safe treatment for the noted pathology. Further studies 
are needed. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested LinQ SI (sacroiliac) joint 
stabilization system, in this case, is not medically reasonable or 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 LinQ SI joint stabilization system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve LinQ sacroiliac (SI) joint stabilization system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 1, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services provided on January 13, 2022. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. Specifically, the Plan denied payment for the radiology services due to the 
incorrect place of service (POS) being billed. However, the Plan has provided no documentation that shows 
what POS was billed by the provider or records from the facility where the service took place to verify. We 
find that the Plan has not substantiated their reasoning for the denial of payment for the services rendered. 
Therefore, we decided that the Plan has to pay for the radiology services provided on January 13, 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 waive the copayment for wound care services provided from March 
8, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that you did not visit this provider 
location. 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 per visit for outpatient surgery.  
 
You have been asked to pay a $250 copayment for the wound care. The wound care falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for wound care services provided from March 8, 
2022, to March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 08, 2022, 
to March 12, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 each 
time you are admitted to an acute care hospital, you pay $200 per day for days 1-5 and $0 after day 5. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. The day 
before you are discharged is your last inpatient day. There were 4 days. $200 x 4 = $800. Therefore, results in 
the total cost sharing amount of $800.   
 You have been asked to pay a $200 copayment per day for days 1-5 for inpatient hospital stay. 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 
copayment for inpatient hospital stay on March 08, 2022, to March 12, 2022.