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 SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for SNF care and can be treated at a lower level of care 
such as at home with home health services or at home with close follow-up with your doctor. 
 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 that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ambulance transportation provided on 
December 31, 2021. 
 
You asked the Plan to waive the deductible for the ambulance transportation. You say that you should have a 
$0 copayment for ambulance services. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Ambulance Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the ambulance transportation was received on December 31, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for ambulance transportation provided on December 31, 
2021.
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 September 1, 2021, to September 23, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not told that the insurance 
company would not cover the last eight days of your stay in full. 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 $0 
copayment for days 1-20 for an in-network skilled nursing facility stay. The contract also says that there is a 
$184 copayment per day for days 21-100. 
 You have not been charged for the first 20 days of the SNF stay from August 26, 2021, to September 15, 2021. 
You have been asked to pay a total of $1, 472, which is a $184 copayment per day for the remaining eight days 
of the SNF stay from September 16, 2021, to September 23, 2021 ($184 copayment x 8 days = $1,472). 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 a skilled nursing facility (SNF) stay provided from September 1, 2021, to September 23, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services coded 01710 provided on January 27, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the documentation supports the services as 
billed. The Plan denied your request. The Plan says that a decision was not made on this appeal within the 
mandated timeframe. 
 
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 01710 is anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and 
elbow; not otherwise specified. 
 
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 anesthesia services. Our reviewer says that the 
documentation supports payment for the services as billed. Our reviewer found that the enrollee is a 52-year-
old female with a history of lateral epicondylitis of the left elbow, s/p left elbow tenotomy under general 
anesthesia and a left supraclavicular block under ultrasound guidance (CPT code 64415) for postoperative 
analgesia on January 27, 2022 (17:01-17:05).  The CPT code 01710-QX-P3 was billed for the patient's 
intraoperative procedure.  The QX modifier (qualified non-physician anesthestist) is used for an anesthetist 
providing anesthesia/monitoring for this case who was supervised/ under medical direction by an MD 
Anesthesiologist during the procedure (15:45 - 16:29).  The enrollee received IV Propofol/Lidocaine/ 
Fentanyl/Ondansetron; laryngeal-mask airway (LMA) inserted. CPT code 01710 is the appropriate anesthesia 
billing code for the surgical procedure performed.  The documentation provided supports the billing/ payment 
of CPT code 01710. 
 
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 anesthesia services have been met. Therefore, we decided that the Plan has 
to pay for the anesthesia services coded 01710 provided on January 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with a single power 
option (K0856) and a power tilt seating system (E1002). 
 
You asked the Plan to pre-approve the Group 3 PWC with power tilt seating system. You say that this should 
be approved due to medical necessity. The Plan denied your request. The Plan says the type of PWC base 
requested is not covered. A Group 3 PWC with no power options may be approved if requested. 
 
The Plan follows Medicare rules. Medicare rules say that Group 4 PWCs coded as K0856 (single power 
options) are only covered if the enrollee requires a power tilt or recline seating system or requires a mounted 
ventilator.   
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 Group 3 PWC with power tilt 
seating system. Our reviewer says that the criteria for the requested PWC base are not met because the criteria 
for the power tilt seating system are not met. Our physician reviewer found the records do not support that the 
enrollee is at high risk for development of a pressure ulcer. There is no reported history of a pressure ulcer, no 
history of flap surgery and no reported current pressure ulcer. Records do not document the need for 
intermittent bladder catheterization or the presence of increased muscle tone or spasticity. 
 
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 Group 3 PWC with power tilt seating system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with a single power 
option (K0856) and a power tilt seating system (E1002).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 23, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 23, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce to copayment for a cystourethroscopy provided on January 
31, 2022. 
 
You asked the Plan to reduce to copayment for a cystourethroscopy. You say that it is unfair that the 
copayment is $100 and not $10 like it was the last time this procedure was done. 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 $100 
copayment for outpatient surgery.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$100 copayment for a cystourethroscopy. A cystourethroscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce to copayment for a cystourethroscopy provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. You say that the enrollee's blood glucose was not 
controlled, and they require alarms to alert them of their blood glucose. The Plan denied your request. The Plan 
says the enrollee is not currently on any intensive insulin regimen. The Plan also says that a FreeStyle Libre 2 
is not medically necessary given the enrollee's current conditions. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on December 6, 2021 to 
December 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the out-of-network chiropractic services. You say that you were advised to send 
the treatment charges to the Plan in order to be reimbursed. The Plan denied your request. The Plan says 
chiropractic services from an out-of-network provider are 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 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. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on December 6, 
2021 to December 13, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an outpatient mental health visit provided 
on January 6, 2022, to January 27, 2022.  
 
You asked the Plan to reduce the cost share for an outpatient mental health visit. You say that the provider is 
in-network, and the claims should be reprocessed. 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 40% 
coinsurance for an out-of-network outpatient mental health visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$54.37, which is 40% coinsurance of the allowed amount for each outpatient mental health visit from January 
6, 2022, to January 27, 2022 ($135.92 allowed amount x 40% coinsurance = $54.37). You have been asked to 
pay a total of $217.48 ($54.37 coinsurance x 4 visits = $217.48). An outpatient mental health visit falls within 
the Outpatient Mental Health 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 reduce the cost share for an outpatient mental health visit provided on 
January 6, 2022, to January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 24, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation to an office visit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the request exceeds the mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation with a maximum trip distance of 60 miles per one-way trip. 
 
We looked at your request and the Plan's rules. The file shows that you are requesting a round-trip distance of 
1,140 miles, or 570 miles per one-way trip. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve routine transportation to an office visit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
heart provided on April 29, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were told this would be covered 
by your insurance and a copayment was never mentioned. 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 $150 
copayment for diagnostic radiology services, including CT scans.  
 
You have been asked to pay a $150 copayment for a CT scan. A 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 a computed tomography (CT) scan of the heart provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 5, 2021, to January 7, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not have to 
pay a copayment due to the hospital stay was due to a previous COVID-19 diagnosis. 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 $295 
copayment per day for days 1-6 for an inpatient hospital stay. The contract also says there is a $0 copayment 
for days 7-90. 
 The record shows you were not admitted to the hospital due to COVID-19. You have been asked to pay a total 
of $590, which is a $295 copayment per day for a two-day inpatient hospital stay from January 5, 2021, to 
January 7, 2021 ($295 copayment x 2 days = $590). There is no charge for the day of discharge. 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 from January 5, 2021, to January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis rendered on January 31, 2022. 
 
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 there is no valid detailed written order. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed supplies. Therefore, we decided that the Plan does not have to pay for the hip orthosis rendered on January 31, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac fusion procedure (27279). 
 
You asked the Plan to pre-approve the sacroiliac fusion procedure. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this procedure is covered when medically 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 the sacroiliac fusion procedure. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found there is no imaging 
study that shows sacroiliac joint instability, fracture, or lesion. Sacroiliac fusion for degenerative back pain is 
experimental. 
 
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 sacroiliac fusion procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a sacroiliac fusion procedure (27279).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 13, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined the 
PCP did not refer the 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 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 laboratory services 
provided on December 13, 2021 by an out-of-network (OON) provider.