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 you want to go to a rehab facility because you can't 
walk at all.  You said that you are not able to use the bathroom at all and cannot prepare your own meals.  You 
said that you are afraid you may fall. The Plan denied your request. The Plan says you do not require a SNF 
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 care. Our reviewer says that SNF 
care is not medically necessary for you. Our physician reviewer found you have stabilized medically and are 
ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a 
daily basis. You are medically stable and can receive further rehab services at a lower level of care.  Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. Admission to a SNF for inpatient skilled rehab services is not 
medically 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on September 28, 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 00912 is a column II code to column I code 99231. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia services rendered on September 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 21, 2021, to January 20, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this denial is appropriate given the clinical scenario. 
 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 pay for the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the enrollee 
did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee 
did not have documented skilled therapy needs. Daily skilled services were not shown to be required to 
establish a maintenance program or to prevent deterioration of the enrollees 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from December 21, 2021, to 
January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 19, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on November 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on 
January 18, 2022. 
 
You asked the Plan to pay for code 70450. 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 as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on 
January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas therapy rendered on December 16, 2020 to July 
6, 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 covered. 
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
provider billed Sanexas electrical stimulation services. These services are not covered when billed by a 
chiropractor. Furthermore, the file shows that the services were not billed with the required NOC compounded 
drug code. Therefore, we decided that the Plan does not have to pay for the Sanexas therapy rendered on 
December 16, 2020 to July 6, 2021.
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 SNF care 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 SNF care. Our reviewer says that SNF 
care is not medically necessary for this patient. Our physician reviewer found the patient has no identifiable 
skilled nursing needs.  Although the patient has skilled therapy needs, the patient does not require these 
services on a daily basis in an inpatient 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code G2212 billed for date of service October 25, 2021. 
 
You asked the Plan to pay for code G2212. You say that two different providers saw the member on this date. 
The Plan denied your request. The Plan says that this code appears to be a duplicate. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole denial rationale is that this code appears to be a 
duplicate.  You provided medical records and an explicit argument that this service was performed by multiple 
providers on this date. The Plan has failed to make any effort to review this documentation or to refute your 
argument.  The burden is on the Plan to support its denial.  By failing to address the submitted medical records 
or to rebut your argument that this service was performed by multiple providers on the same date, we find that 
the Plan has not met its burden. Therefore, we decided that the Plan has to pay for code G2212 billed for date 
of service October 25, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the impact-resistant lenses rendered on February 23, 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 the services are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard lenses and contacts. 
 
We looked at the file and the Plan's rules. The file shows that you received a non-covered lens upgrade. Based 
on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the impact-resistant lenses rendered on February 
23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laparoscopy procedure provided to the enrollee on 
December 8, 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 records do not support the services billed. 
 
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 49329 is "Unlisted laparoscopy procedure, abdomen, 
peritoneum and omentum." 
 
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 that the appropriate additional CPT 
code for this is CPT 15734 for a rives-stoppa type repair with myofascial release. The laparoscopic code for 
recurrent incarcerated hernia repair with mesh is CPT 49657. The myofascial release is not a specific open or 
laparoscopic code and is used as an adjunct code. The unlisted code is not appropriate for this setting.  
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 a laparoscopy procedure provided to the enrollee on December 8, 2021.
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 in the past 24 months you have fallen and broken 
multiple bones.  You said that you need inpatient therapy because you have no help at home and you will be 
able to get the care you need in the SNF. The Plan denied your request. The Plan says SNF care 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 SNF care. Our reviewer says that SNF 
care is not medically necessary. Our physician reviewer found you have no identifiable skilled nursing or 
skilled therapy needs.  You do not require these services on a daily basis in an inpatient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening fundus photography service you received on 
January 10, 2022. 
 
You asked the Plan to pay for the screening fundus photography service. You did not provide a specific 
argument with your appeal request. The Plan denied your request. The Plan says fundus photography is not a 
covered benefit under your vision benefits. 
 
Medicare does not cover screening fundus photography.  In addition, Medicare generally does not cover routine 
vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers routine 
vision exams and eyeglasses or contact lenses under this vision benefit.  There is no coverage for screening 
fundus photography under this benefit.  In addition, when you received this service, you signed a consent form 
stating that you understood that this was not a covered service, and you chose to receive the service anyway. 
 
Based on this information, we decided that the Plan's rules for coverage of the screening fundus photography 
service have not been met. Therefore, we decided that the Plan does not have to pay for the screening fundus 
photography service you received on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction you received from an out-of-network provider 
on January 24, 2022. 
 You asked the Plan to pay for the refraction. You say that your primary care doctor referred you to this 
provider. The Plan denied your request. The Plan says routine vision services are only covered when from the 
designated provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine vision services only when received from a provider in the Plan's designated 
vision network.  The provider you used was not in the designated network for vision services. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the 
refraction you received from an out-of-network provider on January 24, 2022.
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 
abdomen provided on January 10, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you do not know why insurance paid 
so little. 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 $250 
copayment for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for the CT scan. 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 a computed tomography (CT) scan of the abdomen provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that orthotics are needed for the treatment of hammertoes. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for chemotherapy administration and a 
denosumab injection provided on January 19, 2022. 
 
You asked the Plan to reduce the coinsurance for the chemotherapy and injection. You say that you were 
informed that the service would not cost more than $90. The Plan denied your request. The Plan says the 
correct coinsurance was 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 20% 
coinsurance for Part B chemotherapy drugs. 
 
Drug/Service Allowed Amount 20% Coinsurance 
Chemotherapy Administration $74.42 $14.88 
Denosumab $1,272.30 $254.46 
Total:  $269.34 You have been asked to pay $269.34, which is 20% of the allowed amount for the chemotherapy and injection. 
The chemotherapy and injection 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. 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 coinsurance for chemotherapy administration and a denosumab injection 
provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an eye exam and diagnostic test provided 
on February 7, 2022. 
 
You asked the Plan to waive the copayments for the exam and diagnostic test. You say that you do not know 
why you were billed a second time. 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 $35 
copayment for each services to diagnose and treat diseases and conditions of the eye. 
 
Your contract with the Plan also clearly says that you must pay a $75 copayment for diagnostic procedures and tests. 
 
You have been asked to pay a $35 copayment for the exam. The exam falls within the Vision Care benefit 
category. You have also been asked to pay $34.25 for the diagnostic test, which is less than the $75 copayment. 
The diagnostic test falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The total for the visit is $69.25. 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 an eye 
exam and diagnostic test provided on February 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 25, 2021. 
 
You asked the Plan to pay for the medical services. You say that you believe this claim should be paid. The 
Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 18, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on November 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
February 3, 2022, to February 10, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation. You say that you should not be 
charged again since you were only moved to a different building. 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 $395 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were admitted to the inpatient rehab facility from February 3, 2022, to February 10, 
2022. Please note that any transfer to a separate facility is considered a new admission. Therefore, you have been asked to pay $395 per day for the first 5 days for the inpatient rehabilitation. The total for your stay is 
$1,975 ($395 copayment x 5 days = $1,975). The inpatient rehabilitation 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 rehabilitation care 
provided from February 3, 2022, to February 10, 2022.