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

 
We decided that the Plan does not have to pay for ConfirmMDx testing billed with code 81551 for date of 
service February 27, 2023. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is only covered for certain 
indications. 
 
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 testing. Our reviewer says 
that the documentation does not support that the services rendered were medically necessary. Our physician 
reviewer found the enrollee has elevated prostate specific antigen. A prostate biopsy was performed on 
February 27, 2023. and reported on February 28, 2023, revealing benign pathology. ConfirmMDx was ordered 
on the same day as biopsy and ordered prematurely. Per National Comprehensive Cancer Network (NCCN) 
guidelines for Prostate Cancer Early Detection, it is recommended other biomarkers be done to further evaluate 
the risk if the biopsy is negative. Per Centers for Medicare & Medicaid Services (CMS) guidelines LCD 39005, 
criteria are not met for ConfirmMDx as the enrollee was not being considered for a second biopsy due to 
persistent risk factors such as elevated/rising PSA and/or abnormal DRE by repeat testing or an abnormal 
magnetic resonance imaging (MRI). Therefore, the enrollee did not meet criteria for the services rendered. 
 
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 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for ConfirmMDx testing billed with code 81551 for date of service February 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 17, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 22, 2023. 
 
You asked the Plan to pay for the lab services. 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, for 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 the lab services provided on March 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy provided on December 7, 2022. 
 
You asked the Plan to pay for group psychotherapy. The Plan denied your request. The Plan says the clinical 
record does not include any documentation of this service.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of group psychotherapy have been met. 
Therefore, we decided that the Plan does not have to pay for group psychotherapy provided on 
December 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient services provided from 
February 23, 2023, to March 3, 2023. 
 
You asked the Plan to waive the copayment for the inpatient services. You say that you received a bill from the 
provider for $1950 for your rehabilitation services and would like the insurance to pay the balance. You also 
say that you were informed by the Plan via approval letter that this service was approved for coverage, but did 
not advise you that the rehabilitation facility was not part of the Plan's network. 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 $390 
copayment each day for days 1 to 5 and a $0 copayment for additional Medicare covered days for inpatient 
hospital care.  
 
You have been asked to pay a $390 copayment each day for days 1 to 5 and a $0 copayment for additional 
Medicare covered days for the inpatient services. This service 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 the inpatient services provided from February 
23, 2023, to March 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for Injectafer.  
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet criteria for Injectafer.  Our physician reviewer found the record indicates that the 
enrollee has anemia of chronic renal disease. The record provided does not document the failure of oral iron 
therapy or the presence of significant gastrointestinal distress precluding its use. The elements of the coverage 
criteria are not satisfied. The requested service is not 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4261 x 4).

You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 osseous surgery (D4261 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a respiratory assist device provided on 
January 11, 2023, to May 12, 2023. 
 
You asked the Plan to waive the coinsurance for a respiratory assist device. You say that the cost is excessive. 
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 oxygen equipment. 
 
You have been asked to pay 20% coinsurance for a respiratory assist device. This item/service falls within the 
Medicare oxygen equipment 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 $190 ($950 allowed amount x 20% = $190). Therefore, we decided 
that the Plan does not have to waive the coinsurance for a respiratory assist device provided on January 11, 
2023, to May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network specialist visit provided on 
May 30, 2023. 
 
You asked the Plan to reduce the copayment for an in-network specialist visit. You say that you should only be 
getting charged $10 for this visit, not $45. 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 Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an in-network specialist visit. This item/service 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 reduce the copayment for an in-network specialist visit provided on May 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on June 08, 
2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you were not given 
advanced notice that you would have a 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 Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs. This item/service falls within the 
Medicare Part B prescription drugs 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 coinsurance you owe is $956.02, which is 20% of the allowed amount 
for Medicare Part B chemotherapy drugs (4,780.10 allowed x 20% = $956.02). Therefore, we decided that the 
Plan does not have to waive the coinsurance for chemotherapy drugs provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on March 16, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior authorization. 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 facility visit provided 
on March 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram provided on January 26, 2023. 
 
You asked the Plan to pay for the mammogram. You say that you have an authorization for this service. 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 mammogram 
provided on January 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 23, 
2023, to April 7, 2023. 
 
You asked the Plan to pay for SNF care. You say that a continued stay in a skilled nursing facility is medically 
necessary. The Plan denied your request. The Plan says  the enrollee has exhausted the benefits of a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from November 8, 2022, to March 22, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 23, 2023, to 
April 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition solution billed with code B4197 for 
date of service March 31, 2023. 
 
You asked the Plan to pay for the parenteral nutrition solution. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. The medical records 
submitted do not include a physician order for parenteral nutrition solution; compounded amino acid and 
carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 g of 
protein  premix. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the parenteral nutrition solution 
billed with code B4197 for date of service March 31, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed preferred medications. 
 
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 the medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found step therapy, as outlined by the plan, requires that one of the preferred viscosupplemental treatments 
(Orthovisc, Synvisc, Synvisc One, or Monovisc) be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered or that the plan's additional required drugs 
would likely be less effective and/or likely have adverse effects 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor identified with code E2310. 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that electronic connections are only covered for 
certain indications.   

We looked at the file and Medicare rules. Review of the file shows that the enrollee is independent with 
transfers, self-feeding, and grooming. There is not a medical need to control the approved power feature though 
the joystick. The power feature can be controlled using its own switch. This switch can be made any size 
without asking for a separate request. It can be made from any material without asking for a separate request. 
All of this can be done without the need to use the joystick to control the power feature. Based on this 
information, we decided that Medicare rules for coverage of an electronic connection between wheelchair 
controller and one power seating system motor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection between wheelchair controller and one power seating system 
motor identified with code E2310.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 19, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the 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 laboratory services 
provided on May 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient surgery provided on 
February 24, 2023, to March 10, 2023. 
 
You asked the Plan to waive the copayment for each outpatient surgery. You say that you say that you do not 
agree with the charges. 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $275 copayment for each outpatient surgery. This item/service 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. The 
total you owe is $825 ($275 copayment x 3 visits = $825). Therefore, we decided that the Plan does not have to 
waive the copayment for each outpatient surgery provided on February 24, 2023, to March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you felt an in-network specialist is not suitable for your needs. The Plan denied your request. The Plan says a provider is 
accepting new patients and specializes in endoscopy and gastroenterology procedures. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.