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

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from May 1, 2021, to May 31, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were told your stay would be 
covered by insurance. The Plan denied your request. The Plan says the claim for April 27, 2021, through April 
30, 2021, reprocessed with zero copayment. The Plan also says that the copayment for May 1, 2021, through 
May 31, 2021, 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 $184 
copayment each day for days 21-60 for Skilled nursing facility (SNF) care.  
 You have only been asked to pay a $2,024 copayment for 11 days of the SNF stay ($184/day x 11 days = 
$2,024). A SNF stay 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 the skilled nursing facility (SNF) stay provided from May 1, 2021, to 
May 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx test (81551) provided December 20, 2021. 
 
You asked the Plan to pay for the ConfirmMDx test. You say that you are the sole source provider for the 
ConfirmMDx test. Therefore, this test cannot be performed at a contracted laboratory. The Plan denied your 
request. The Plan says the service does not meet Medicare criteria. 
 
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 ConfirmMDx test. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that the enrollee is a 67 year old male with 
R97.0, elevated prostate specific antigen.  Requisition indicates date of biopsy was 12/20/21. ConfirmMDx was 
done immediately after the first biopsy and ordered prematurely. Deny request for 81551. The enrollee was not 
being considered for a 2nd biopsy for persistent risk factors as required per CMS guidelines. Medicare 
guidelines require previous negative biopsy done in last 24 months and persistent risk factors for ConfirmMDx 
to be approved. Per NCCN guidelines, ConfirmMDx is not recommended to be done at the same time as the 
biopsy. NCCN has recommended other biomarkers be done to further evaluate the risk if the biopsy is negative. 
The review has determined that the medical records provided do 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 ConfirmMDx test have not been met. Therefore, we decided that the Plan 
does not have to pay for the ConfirmMDx test (81551) provided December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit (99203) provided on July 2, 2021. 
 
You asked the Plan to pay for a new patient office visit. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this service is not covered when billed 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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a new patient office visit (99203) provided on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or 
injection of a major joint or bursa (20610) provided on December 3, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 provided at an outpatient hospital facility, per date of service.  
 
 You have been asked to pay $270.57 for the outpatient surgery provided at an outpatient hospital facility. This 
is the Plans allowed amount for this service which is less than the applicable copayment. 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 arthrocentesis, aspiration and/or injection of a major joint or 
bursa (20610) provided on December 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Retacrit is medically reasonable and necessary for the enrollee. The 
documentation does not support that the Retacrit is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on April 30, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on April 30, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a virtual colonography. 
 
You asked the Plan to pre-approve a virtual colonography. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a virtual colonoscopy is covered when specific 
criteria are met. 
 
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 a virtual colonography. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the record indicates that the 
enrollee underwent a colonoscopy approximately five years ago. The record indicates that the enrollee has not 
had a recent colonoscopy. The record does not document that the enrollee has a covered indication for the 
requested service or a contraindication to an instrument colonoscopy. The elements of the coverage criteria are 
not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a virtual colonography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a virtual colonography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care office visit provided on 
September 23, 2021. 
 
You asked the Plan to waive the copayment for a primary care office visit. You say that you were injured at 
work and had to see your primary care physician. You also say that you should not be liable. 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 $10 
copayment for a primary care office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$10 copayment for a primary care office visit. A primary care 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 a primary care office visit provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (cgm), includes all supplies and accessories, 1 month supply (K0553). 
 
You asked the Plan to pay for the CGM device supply allowance. You say that please review the attached 
medical records. The Plan denied your request. The Plan says documentation did not support the billed supply 
code. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM device supply allowance. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the documentation submitted did not sufficiently 
support the billed supply code. The review indicates that the enrollee does have diabetes mellitus. There is no 
documentation provided indicating that the enrollee is insulin treated with three or more daily administrations 
of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. There is no documentation 
provided indicating that the enrollees insulin treatment regimen requires frequent adjustment by the enrollee 
on the basis of BGM or CGM testing results. 
 
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 CGM device supply allowance have not been met. Therefore, we decided 
that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (cgm), 
includes all supplies and accessories, 1 month supply (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on November 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for drug testing provided on November 18, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular stress test (93017) and the hospital 
outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on November 30, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the cardiovascular stress test (93017) and the hospital outpatient clinic visit 
(G0463) rendered by the out-of-network (OON) provider on November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that the requested LTACH care is a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for LTACH care have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you appear to be improved somewhat but are still requiring short-term acute care 
services to safely complete care until more stable for discharge to a lower level of care. You do not require 
services at the LTACH that are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require another 3-4 
weeks to transition from her acute illness. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the current condition is critical with guarded prognosis, per the provider note on 
May 1, 2022. There is no documentation provided indicating medical necessity for LTACH services. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided on January 11, 
2021, April 1, 2021, July 21, 2021, and October 20, 2021. 
 
You asked the Plan to waive the coinsurance for ostomy supplies. You say that you were never advised of the 
10% coinsurance and that you need these items for your well-being. The Plan denied your request. The Plan 
says the coinsurance 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 10% 
coinsurance for ostomy supplies. The allowed amount of these supplies is $38.70, resulting in a coinsurance 
amount of $15.48 ($38.70 x 10% = $3.87 x 4 visits = $15.48).  
 You have been asked to pay 10% coinsurance for ostomy supplies. Ostomy supplies fall within the Prosthetic 
devices 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 ostomy 
supplies provided on January 11, 2021, April 1, 2021, July 21, 2021, and October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on December 2, 2021. 
 
You asked the Plan to pay for an annual wellness visit. You say that you have no control over what kinds of 
services were performed. The Plan denied your request. The Plan says an annual physical exam is only allowed 
once per calendar year, and the benefit had been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on  
December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) stay 
provided from April 16, 2021, to May 26, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 day for days 1-58 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $3.750 copayment for a SNF stay provided from April 16, 2021, to April 30, 
2021 ($250 x 15 = $3,750) and a $864.93 copayment for a SNF stay from May 1, 2021, to May 26, 2021, you 
met your maximum out-of-pocket during this time and were charged less for those 25 days. 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) stay provided from April 16, 2021 to 
May 26, 2021.