Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on October 6, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 Home Health Services provided on October 6, 
2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with polyp 
removal provided on January 28, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not have a 
copayment for such required follow ups to the regular procedure. 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 $350 
copayment for outpatient surgery at an outpatient hospital. The Plan contract also says that if you receive a 
separate additional non-preventive evaluation and/or service, a copayment will apply. 
 The record shows this claim was approved, and you have a cost share amount. According to the EOC, if you 
receive a separate additional non-preventive service, a copayment will apply. You have been asked to pay a 
$350 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 a diagnostic colonoscopy with polyp removal 
provided on January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
December 29, 2021, by an OON provider. 
 
You asked the Plan to pay for the DME. You say that the enrollee received the equipment when they were 
discharged, and you are unable to obtain an authorization. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided 
on December 29, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on November 15, 2021. 
 You asked the Plan to pay for the testing services. You say that the testing provides actionable results. The Plan 
denied your request. The Plan says the testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing services. Our physician reviewer 
found that CxBladder is considered experimental/investigational as a screening test for urothelial cancer. 
Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the 
results of CxBladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results 
in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-
stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over 
cytology but there is lack of validation of clinical utility. Some of the recently developed markers aim to 
change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive 
investigations. Further prospective validations are needed to confirm these findings. Therefore, the CxBladder 
testing provided was not medically reasonable and necessary and did not impact clinical outcome.  
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder testing provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multianalyte assays with algorithmic analyses (0012M) 
provided November 1, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you believe the evidence supporting the use 
of Cxbladder as medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says this service does not meet Medicare criteria of being medically reasonable 
and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this test has not been evaluated by the MolDx Program's technical assessment process 
and LCD 35396 cites it as noncovered. The review has determined that the medical records provided did not 
meet the requirements listed in the LCD for Medicare coverage. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the multianalyte assays with algorithmic analyses (0012M) provided November 1, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you do not drive and 
have no other means of transportation. The Plan denied your request. The Plan says the requested services 
exceed your benefit allowance for routine transportation services. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that the Plan has provided coverage for 20 one-way routine transportation in the 2022 calendar year.  Based on this information, 
we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the visit was for removal of sutures 
from a previous surgery and you don't believe you should be charged a copay. 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 when x-rays are performed in a physicians office or an Independent Diagnostic Testing 
facility(IDTF).  
 
 
  You have been asked to pay $15 for the x-ray. The x-ray 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 
the x-ray provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the power operated scooter provided on 
February 19, 2022. 
 
You asked the Plan to waive the coinsurance for a power operated scooter. You say that you don't think you 
should have to pay 0.99 more than you usually pay for your scooter. The Plan denied your request. The Plan 
says the coinsurance 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 20% 
coinsurance for Advanced Durable Medical Equipment, which includes custom or specialty wheelchairs and 
scooters. 
 
 
  You have been asked to pay $19.67 (allowed=$98.33 x 20%) for the power operated scooter. A power operated 
scooter 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 the power operated scooter provided on February 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 11, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were under the 
impression the service was covered due to being unable to drive yourself to the hospital and it was medical 
necessary. 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 $200 
copayment for ground ambulance services.  
 
You have been asked to pay a $200 copayment for ambulance services. Ambulance services falls 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 ambulance services 
provided on July 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit (code 99211) billed for date of 
service June 2, 2021. 
 
You asked the Plan to pay for the chiropractic office visit. You say that this should be paid as if you were in-
network. The Plan denied your request. The Plan says this code is not a covered chiropractic service. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit (code 99211) billed for date of service June 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim partial dentures - mandibular (D5821) provided 
by a participating provider. 
 
You asked the Plan to pre-approve interim partial dentures. You say that you would like the Plan to approve 
this dental work. The Plan denied your request. The Plan says the requested dental work is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
interim partial denture - mandibular (D6821) provided by a participating provider
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic mammography provided on February 15, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a diagnostic mammography. You say that no ultrasound was needed to this 
procedure was not a diagnostic mammogram, and you were seen for a regular mammogram, and this should be 
covered. The Plan denied your request. The Plan says prior authorization is required for diagnostic testing, and 
after review, it has been determined that the services received were for a diagnostic mammogram. The Plan 
also says that they have contracted your provider to inquire if this was truly a diagnostic exam, and the office 
advised them that this was a diagnostic exam after seeing you six months prior and finding abnormal findings 
in your results. 
 
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 a diagnostic mammography provided on February 
15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) of the facet joint 
nerves. 
 
You asked the Plan to pre-approve the repeat RFA procedure. You say that it is felt that this treatment is 
helpful enough to be warranted. The Plan denied your request. The Plan says the criteria for a repeat RFA are 
not met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months. 
 
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 repeat RFA procedure. Our 
reviewer says that the requested RFA procedure is not shown to be reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain. She had an RFA procedure in June 2020 
which provided 50% pain relief for six months. However, in September 2021, another RFA provided 60% pain 
relief but only for 4 months. Magnetic resonance imaging (MRI) shows a disc bulge which could be another 
cause of the enrollee's pain. 
 
Because the enrollee did not achieve adequate pain relief for the required length of time from the previous RFA, repeat of this procedure is not medically reasonable and 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 repeat RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repeat radiofrequency ablation (RFA) of the facet joint nerves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 20, 2021, to October 25, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee did not 
want to stay in the hospital, and you would like the copayment to be waived. The Plan denied your request. The 
Plan says the proper copayment was applied for the service that was rendered. 
 
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 a $360 copayment for each day for days 1 to 5 for Medicare-covered hospital care. $0 copayment for 
additional Medicare-covered days. From October 20, 2021, to October 25, 2021, there was a total of 5 days. 
The total copayment amount for the 5 days was $1,800 ($360 copayment per day x 5 days). The enrollee has been asked to pay a $1,800 copayment for the inpatient hospital stay. The inpatient hospital 
stay falls within the Inpatient Hospital 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 an inpatient hospital stay provided from October 20, 2021, to October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Urgent care services on January 18, 2022. 
 
You asked the Plan to waive the copayment for Urgent care services. You say that a specialist visit is usually 
$15. The Plan denied your request. The Plan says it was determined that an urgent care visit was rendered on 
January 18, 2022 in an outpatient setting. 
 
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 Urgent care services.  
 
You have been asked to pay a $30 copayment for Urgent care services. Urgent care services 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 Urgent care 
services on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand system. 
 
You asked the Plan to pre-approve a combination sit to stand system. You say that this is medically necessary. 
The Plan denied your request. The Plan says that there is no specific reason given why this brand and model is 
needed over a standard system. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit to stand system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade (J1745) and administration. 
 
You asked the Plan to pre-approve Remicade. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Humira, Enbrel, or 
Xeljanz. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Remicade. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Humira, Enbrel or Xeljanz. The reviewer 
found that there is no indication that the plan's required drugs would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade (J1745) and administration.