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

 
We decided that the Plan does not have to pay for surgical arthroscopy provided to the enrollee on June 10, 
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 the operative report did not contain documentation of the denied code. 
 
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 29823 is [*****enter CPT Codebook definition*****]. 
 
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 operative report describes that all 
reported procedure codes were performed on the right shoulder. In this case, this procedure would not be 
reported separately. Shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) 
even if the extensive debridement is performed in a different area of the same shoulder. If another arthroscopy 
procedure is billed and paid for the same day, on the same shoulder, for the same beneficiary, on the same date of service, the extensive debridement (code 29823) is not separately payable and CPT code 29823 will be 
denied. 
 
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 surgical arthroscopy provided to the enrollee on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SelectMDx test provided to the enrollee on August 
11, 2021. 
 
You asked the Plan to pre-approve to pay for. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documented result of prior prostate biopsy. 
 
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 to pay for. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that in this case,the patient did not undergo a previous prostate biopsy. The 
review has determined that the services at issue in this case are not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of to pay for have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the SelectMDx test provided to the enrollee on August 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the 
member required skilled rehab services to improve function due to weakness and deconditioning. There were 
no skilled nursing needs. As of May 20, 2022, the member did not require any skilled nursing or rehab services 
on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member 
did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the 
member did not require any skilled services on an inpatient basis, at a SNF level of care as of May 20, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have been in bed for six (6) day and are not 
strong enough to go home. The Plan denied your request. The Plan says you have been in bed for six (6) day 
and are not strong enough to go home. 
 
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 you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs.  Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of your 
condition. 
 
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a neurosurgery specialist office visit and a 
hip x-ray provided on January 19, 2022. 
 
You asked the Plan to waive the copayments for a specialist office visit and an x-ray. You say that if your 
doctor told you how much the services were going to cost, you would not have had them done. You also say 
you cannot afford 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 $15 
copayment for an in-network outpatient x-ray. The Plan contract also says that enrollees must pay a $25 
copayment for an in-network specialist office visit. 
 
You have been asked to pay a $15 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a $25 
copayment for a specialist office visit. A specialist 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 copayments for a 
neurosurgery specialist office visit and a hip x-ray provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 17, 2021, to December 23, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were released too early 
from a previous inpatient stay. You say that you had to return to the ER and were admitted a second time, and 
you should not be responsible for another copayment. 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 $175 per 
day for days 1-7 and $0 per day for additional days for each inpatient admission.  
 The file shows that you were in the hospital from December 17, 2021, to December 23, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $175 per day for the first 6 days of 
inpatient care. The total for your stay is $1,050 ($175 copayment x 6 days = $1,050). The inpatient care 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 
inpatient hospital care provided from December 17, 2021, to December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis 
(74177) and a CT scan of the chest (71260) provided on January 3, 2022. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis and for a CT scan of the 
chest. You say that you cannot afford to pay for the service out of pocket. The Plan denied your request. The 
Plan says the cost-share was applied correctly. The Plan explained that the CT scan of the abdomen and pelvis 
(74177) is denied due to the service being incompatible with your diagnosis. Furthermore, the Plan says that 
you cannot be billed for a denied service, which means you are only responsible for payment of the CT scan of 
the chest (71260).  
 
 
 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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $150 copayment for a CT scan of the chest (71260). 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.  
 
Additionally, the denied CT scan of the abdomen and pelvis (74177) does not require any cost sharing. You are 
not liable for payment of denied services. Therefore, we decided that the Plan does not have to waive the 
copayment for a Computed Tomography (CT) scan of the abdomen and pelvis (74177) and a CT scan of the 
chest (71260) provided on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress for the 
enrollee. 
 You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of multiple pressure ulcers of the trunk or pelvis which have 
failed comprehensive management. 
 
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 the mattress. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has single stage II sacral pressure ulcer. The documentation does not show multiple pressure 
ulcers as noted. The enrollee has not had a myocutaneous flap or skin graft within the past 60 days. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered pressure reducing air mattress for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the documentation 
provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented 
skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, as a practical matter, can be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Radium ra223 dischloride provided on 
November 22, 2021, and December 20, 2021. 
 
You asked the Plan to waive the coinsurance for Radium ra223 dischloride. You say that there is another liable 
party for payment of this treatment. You also say that the office staff should have contacted them for coverage. 
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 Part B drugs.  
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay $2,967.84, which is 20% coinsurance of the allowed amount for each Radium ra223 dischloride provided on November 22, 2021, and December 20, 2021 ($14,839.20 allowed amount x 20% coinsurance = $2,967.84). 
You have been asked to pay a total of $5935.68 ($2,967.84 coinsurance + $2,967.84 coinsurance = $5,935.68). 
Radium ra223 dischloride 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for Radium ra223 dischloride provided on November 22, 2021, and 
December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a urinalysis provided on November 15, 
2021. 
 
You asked the Plan to waive the copayment for a urinalysis. You say that the lab work was performed as part 
of the wellness visit and should be covered 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 $10 
copayment for laboratory tests. The Plan contract also says that enrollees must pay a $0 copayment for an 
annual physical. The contract says that if you receive additional services, an additional cost share may apply. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed about of $3.48, which is less than the $10 copayment for a urinalysis. A urinalysis 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 urinalysis provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99214 x 2) and the telephone evaluation and 
management services (99441 x 2) rendered by the out-of-network (OON) provider from October 13, 2021, 
through February 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visits (99214 x 2) and the telephone evaluation and management 
services (99441 x 2) rendered by the out-of-network (OON) provider from October 13, 2021, through  
February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested group 2 
power wheelchair with single power option and other accessories are medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested group 2 power wheelchair with 
single power option and other accessories. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the enrollee does not meet criteria for the requested group 2 power wheelchair with 
single power option and other accessories. Our physician reviewer found the enrollee is with a history of 
diabetes, peripheral neuropathy, hypertension, chronic obstructive pulmonary disease (COPD), obesity, rheumatoid arthritis, low back pain, and right shoulder pain. The enrollee has fluctuations in her ability to 
ambulate and has been using a rolling walker or a cane. The enrollee is unable to propel a manual wheelchair 
due to pain, weakness, and fatigue. 
 
The clinical documentation does not support that the enrollee has a personal mobility deficit that impairs 
participation in mobility related activities of daily living (MRADLs) and cannot be helped by the use of a 
walker, cane or manual wheelchair. The clinical documentation does not support that the enrollee meets 
Medicare criteria for the requested group 2 power wheelchair with single power option and remaining 
accessories. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued SNF services. You say that you are unable to get the enrollee to 
an assisted living until the paperwork is done and the SNF is not letting her go home because it makes the 
transportation difficult from home to the assisted living facility. The Plan denied your request. The Plan says 
this is not medically necessary. 
 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 continued SNF services. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does 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 continued SNF services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) services.