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

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like to see continue to see this 
doctor. The Plan denied your request. The Plan says there are multiple in-network providers available for these 
services. 
 
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. Please contact the Plan for a list of 
available in-network providers. 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 physician services to be 
provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from October 1, 2019 to 
December 2, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The rules say that items and 
services furnished outside the United States are not covered.   
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received elective surgery 
while outside of the United States and received inpatient services from October 1, 2019 to December 2, 2019. 
The file shows that you were undergoing preoperative testing performed over a week prior to the surgery, 
further demonstrating the surgery was a planned procedure while out of the country. Medicare does not cover 
services provided while outside the United States. Therefore, we decided that the Plan does not have to pay for 
the inpatient services provided from October 1, 2019 to December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 25, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for psychiatric evaluation. You say that your provider depends on the facility to 
verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because this provider is out-of-network with the Plan and the referring facility is also 
out-of-network with the Plan. 
 
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 has network providers 
available who can provide 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 medical services provided on February 25, 
2020 by an out of network (OON) provider.
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 October 4, 2019 to October 31, 2019.
You asked the Plan to waive the copayment for SNF stay. You say that you were not informed of a copayment for this stay and should not be billed for these services. The Plan denied your request. The Plan says the copayment amount 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 copayment per day for days 1 to 20 and $172 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) Care. This portion of the SNF stay lasted 28 days, resulting in a copayment obligation of $1,376. You have been asked to pay $0 copayment per day for days 1 to 20 and $172 copayment per day for days 21 to 100 for SNF stay. 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 a Skilled Nursing Facility (SNF) stay provided from October 4, 2019 to October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for nuclear medicine provided by an out-of-
network hospital on February 18, 2020 to February 21, 2020. 
 
You asked the Plan to waive the coinsurance for nuclear medicine. You say that this is an in-network hospital. 
The Plan denied your request. The Plan says they verified at the time of these services the outpatient hospital 
was out-of-network. 
 
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 40% 
coinsurance for outpatient diagnostic tests/other outpatient tests/out-of-network.  
 
You have been asked to pay a 40% coinsurance of the allowed amount for nuclear medicine provided by an 
out-of-network provider. The total allowed amount is $1,999.30. The total amount you are being asked to pay 
is $799.72 ($1,999.30 x 40% = $799.72). Nuclear medicine falls within the outpatient diagnostic tests/other 
outpatient tests/out-of-network 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 
nuclear medicine provided by an out-of-network hospital on February 18, 2020 to February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on February 14, 2020.
You asked the Plan to pay for the durable medical equipment. The Plan denied your request. The Plan says that
the Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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
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 durable medical equipment provided on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on May 9, 2019 to May 13, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you strongly disagree with this copayment amount. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $345 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $345 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $1,380 ($345 x 4 days = $1,380). An 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 an inpatient hospital stay provided by a participating provider on May 9, 2019 to May 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from November 7, 2019 to November 20, 2019.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 chiropractic services provided from November 7, 2019 to November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve glucose test strips. 
 
You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your 
request. The Plan says you must meet all of the coverage criteria, which includes a diagnosis of diabetes. 
 
The Plan must follow Medicare rules. Medicare rules say that glucose monitor supplies are only when covered 
when the monitor itself is 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 the strips. Our reviewer says that the 
requested test strips are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that you meet the criteria for a glucose 
monitor itself, therefore indicating the request for the strips is not medically necessary either. You have a recent 
hemoglobin A1c level of less than 4.2% (on no anti-diabetic medication) which does not meet diagnostic 
criteria for diabetes or pre-diabetes. 
 
 
We looked at this physician's review, the file, and Medicare rules. There is no evidence of a diagnosis of 
diabetes. Based on this information, we decided that Medicare rules for coverage of the strips have not been 
met. Therefore, we decided that the Plan does not have to pre-approve glucose test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on August 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician?s intent that the tests be performed. 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 the 
drug testing services provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction by neurolytic agent services coded 64635 and 
64636 provided on October 22, 2019. 
 
You asked the Plan to pay for the destruction by neurolytic agent services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by 
the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 64635 and 64636 are not supported in the medical record. Specifically, the operative 
report did not include documentation of paravertebral facet joint nerve(s) destruction by neurolytic agent with 
imaging guidance (fluoroscopy or CT) for a single facet joint nerve at the lumbar or sacral spine level; 
therefore, code 64635 cannot be verified. Also, the operative report did not include documentation of 
paravertebral facet joint nerve(s) destruction by a neurolytic agent with imaging guidance (fluoroscopy or CT) 
for each additional lumbar or sacral facet joint (listed separately in addition to code for primary procedure); 
therefore, code 64636 cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the destruction by neurolytic agent services have not been met. Therefore, we decided that the Plan 
does not have to pay for the destruction by neurolytic agent services coded 64635 and 64636 provided on 
October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on May 8, 2019 to July 28, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the referring facility and provider are also out-of-network. 
 
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 has network providers 
available who can provide 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 skilled nursing services provided on May 8, 2019 
to July 28, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery and Part B drug 
services rendered on April 24, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you were informed you would 
have a $0 copayment for these services. 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 a 20% 
coinsurance for Medicare Part B prescription drugs and a $225 copayment per visit for an outpatient surgery or 
procedure. 
 
Review of the file shows that you received an alteplase recombinant injection on April 24, 2020. You have 
been asked to pay a 20% coinsurance for these services, for a total of $12.85. These services fall 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.  
 
The file shows that you received outpatient surgical services on April 24, 2020. You have been asked to pay a 
$225 copayment for these services. These services fall within the outpatient surgery benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. 
 
The total amount you have been asked to pay for these services is $237.85. 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 outpatient surgery and Part B drug services rendered on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network provider.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary to improve strength 
and mobility. The Plan denied your request. The Plan says the SNF level of care criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not have 
complex wound care or other ongoing SNF level SN need. His functional level does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. He does not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this 
enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ostomy skin barrier, with flange without built-in convexity 
(A4414) Ostomy pouch, for use on barrier with non-locking flange (A4425) provided February 27, 2020. 
 
You asked the Plan to pay for the Ostomy supplies. You say that you wish to appeal the denial of this claim, 
according to Medicare guidelines it was denied in error. The Plan denied your request. The Plan says payment 
for this is included in Part A SNF payment per Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the Ostomy supplies was used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for Ostomy skin barrier, with flange without built-in convexity (A4414) Ostomy pouch, 
for use on barrier with non-locking flange (A4425) provided February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology care to be provided by the out of network
(OON) provider.
You asked the Plan to pre-approve the neurology care. You say that you would like to continue to see this
neurologist as he has been following your case from the beginning. The Plan denied your request. The Plan
says medically necessary care is available with a provider within the Plan's network.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve neurology
care to be provided by the out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the drug testing services provided on June 17, 2019.