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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a two-wheeled walker with supervision and is contact guard assist for transfers. 
Provided records do not document a significant decline in your functional status to necessitate further daily 
inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Records do not document that further services in the home with home health care or in 
a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement services provided to the enrollee on 
September 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code would not be separately reported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11721 is "Debridement of nail(s) by any method(s); 6 or 
more." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report does not include 
enough documentation to confirm the Keratoma debridement was not performed on the same toe as the nail 
debridement. Therefore, this procedure cannot be verified. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for nail debridement services provided to the enrollee on September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not require daily skilled therapy services due to your level of 
function and would be equally well served at an alternative level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for hyperbaric oxygen chamber services 
provided from October 11, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayments for the hyperbaric oxygen chamber services. You say that the 
provider informed you that there would be no copayments for the services. 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 $45 
copayment for each specialist visit.  
 
The file shows a total of 34 visits for the hyperbaric oxygen chamber services. You have been asked to pay a 
$45 copayment for 33 of those visits, and $1.11 for the final visit. The total for all visits is $1,531.11.  The hyperbaric oxygen chamber services fall within the Physician/Practitioner Services, Including Doctor's 
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 copayments for hyperbaric oxygen 
chamber services provided from October 11, 2021, to December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oxygen Equipment provided on October 25, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Oxygen Equipment. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says prior authorization is required for 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 Oxygen Equipment provided on October 25, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 25, 2021. 
 
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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation and management service (99442) 
provided on November 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a telephone evaluation and management service. You say that this provider is 
credentialed per the Plan's guidelines, and you want this claim processed without the authorization since this is 
a network provider The Plan denied your request. The Plan says this provider's effective date with the Plan is 
after the claim's date of service, therefore on the date of service, the provider was still non-participating with 
the Plan. The Plan also says that this provider is not a network provider with the Plan and the services were not 
referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 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 telephone evaluation and management service 
(99442) provided on November 17, 2021, by an out-of-network (OON) provider.
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 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 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 the medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
April 25, 2022, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care from April 25, 2022, and 
forward. You say that the requested continuation of inpatient mental health care from April 25, 2022, and 
forward is medically necessary. The Plan denied your request. The Plan says the requested continuation of 
inpatient mental health care from April 25, 2022, and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 continuation of inpatient mental 
health care from April 25, 2022, and forward. Our reviewer says that the requested continuation of inpatient 
mental health care from April 25, 2022, and forward is not medically necessary. Our physician reviewer found 
this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was 
not a danger to herself or others, with no auditory hallucinations or visual hallucinations while being 
cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. 
It did not appear that the services were reasonably expected to improve the enrollees condition or for the 
purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however 
the entire record is not present. It did appear that the records were supervised and evaluated by a physician. 
Based upon review of the records provided the enrollee does not meet the criteria for continued acute inpatient 
mental health treatment for the dates in question of April 25, 2022, and forward as this enrollee was not shown 
to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was 
cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any 
treatment required for acute threats of safety. 
 
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 continuation of inpatient mental health care from April 25, 2022, and 
forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation 
of inpatient mental health care from April 25, 2022, and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 20, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says coverage extends 
only to treatment by means of manual manipulation of the spine to correct a subluxation. 
 
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 an office visit provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on December 6, 
2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that it is you understanding that her 
policy would cover all charges related to the Covid-19 virus. The Plan denied your request. The Plan says the 
copayment applied is correct. You can find the COVID-19 testing and treatment coverage on pages 63 and 64 
in the EOC. 
 
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 $180 
copayment for advanced imaging services.  
 
 You have been asked to pay $142.13 for the CT scan, which is less than the $180 copayment. The CT scan 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 CT scan provided on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery. 
 
You asked the Plan to pre-approve cataract surgery. You say that you cannot see out of your right eye when 
you cover your left. You say that you are diabetic, you are not able to drive, and your vision is not getting any 
better. The Plan denied your request. The Plan says there is no documentation of visual impairment, intra-
ocular or lens- related disease. 
 
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 cataract surgery. Our reviewer says that 
the enrollee does not meet the LCD coverage criteria. Our physician reviewer found that the case file does not 
contain clinical documentation that you have a cataract causing symptomatic impairment of visual function, 
concomitant intraocular disease, lens-induced disease threatening vision, high probability of accelerating 
cataract development or cataract interfering with the performance of vitreoretinal surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cataract surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cataract surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on December 9, 2021. 
 
You asked the Plan to waive the copayment for An office visit. You say that you do not agree with the 
copayment assessment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for office visit.  
 
You have been asked to pay a $35 copayment for an office visit. An office visit falls within the 
Physician/Practitioner Services, including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an arthrocentesis and a Orthovisc injection 
provided on August 17, 2021. 
 
You asked the Plan to waive the cost share for an arthrocentesis and an injection. 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 20% 
coinsurance for in-network Part B drugs. The Plan contract also says that enrollees must pay a $325 copayment 
for in-network outpatient surgery at an outpatient hospital. You have been asked to pay $39.47, which is 20% coinsurance for an injection ($197.33 allowed amount x 
20% coinsurance = $39.47). An injection falls within the Medicare Part B Prescription Drugs benefit category.  
 
You have also been asked to pay a $325 copayment for an arthrocentesis. An arthrocentesis falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You have been asked to pay a total of $364.47 ($39.47 coinsurance + $325 
copayment = $364.47). 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 cost share for an arthrocentesis and a Orthovisc 
injection provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam (92015, 92014) provided on 
October 22, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. 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 $40 
copayment for Vision care.  
 
 
  You have been asked to pay a $40 copayment for an eye exam. Eye exams fall within the Vision 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 eye exam (92015, 92014) provided on 
October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lightweight wheelchair (K0003) and miscellaneous durable 
medical equipment, ramp (E1399) provided November 16, 2021 to November 20, 2021. 
 
You asked the Plan to pay for the wheelchair and ramp. You say that you should be reimbursed for the cost of 
the wheelchair and ramp expenses. It was reasonable and medically necessary as prescribed by your doctor. 
The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 
 
 
  
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for lightweight wheelchair (K0003) and 
miscellaneous durable medical equipment, ramp (E1399) provided November 16, 2021 to November 20, 2021.