Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from February 2, 2021, 
to February 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that verification of the enrollee having 
straight Medicare was verified on January 22, 2021, prior to the patient admitting. The Plan denied your 
request. The Plan says this provider is not participating with the Plan, and a prior authorization was never 
requested by the out-of-network provider or member. 
 
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 inpatient hospital services provided from February 
2, 2021, to February 13, 2021, by an out-of-network (OON) provider.
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 the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the enrollee does not require skilled services on a daily basis. The plan says that the services the enrollee 
requires can safely be received in a different setting.  
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 there is no documentation that the 
enrollee requires skilled nursing services. Records do not document the need for intravenous medications, new 
tube feeding, or ostomy care or daily complex wound care. The enrollee does require skilled therapy services, 
but not on a daily basis. There is no documentation that the enrollee requires the services on an inpatient basis, 
only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care 
facility on a part time basis appear 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2781, V2025) provided on December 14, 
2021. 
 You asked the Plan to pay for the eyeglasses. You say that you did not know this provider was out-of-network 
and these services would not be covered. The Plan denied your request. The Plan says the provider in this case 
is not part of the Plan's specified vision vendor network. You do not have out-of-network benefits; therefore, 
these services are denied. 
 
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 these services when they are received from a provider within the Plans routine 
vision vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses (V2781, V2025) provided on December 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation, wheelchair van. 
 
You asked the Plan to pre-approve non-emergency transportation, wheelchair van. You say that you feel 
services should be covered as the enrollee needs dialysis services on Monday, Tuesday, Wednesday, and 
Friday. You also say that at this time, the enrollee is currently in a skilled nursing facility and has no other way 
of transport. The Plan denied your request. The Plan says a wheelchair van (chair car) transportation is not 
covered by Medicare even if provided by an ambulance company. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency transportation, wheelchair van.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (S9359) provided July 26, 2021. 
 
You asked the Plan to pay for the infusion services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the billed code is not 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. 
 
We find that CPT code S9359 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "I" and is invalid for Medicare use. Based on this information, we 
decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that 
the Plan does not have to pay for infusion services (S9359) provided July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring provided on 
August 11, 2021. 
 
You asked the Plan to pay for the monitoring services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the enrollee is not on insulin therapy. 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 does not indicates that the enrollee uses 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 the 
monitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulatory continuous glucose monitoring provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation with initiation of diagnostic and treatment program; comprehensive (92004) and determination of 
refractive state (92015) provided on June 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam and eye refraction. You say that you have not needed a 
referral for a routine eye exam in the past. The Plan denied your request. The Plan says the vision services 
provided were medical in nature and are not covered because they were provided OON. 
 
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 the ophthalmological services: medical 
examination and evaluation with initiation of diagnostic and treatment program; comprehensive (92004) and 
determination of refractive state (92015) provided on June 14, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested bed. You say that you are only weight bearing in one leg. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
We looked at the file and the rules. While a total electric hospital bed may be appropriate in this case, neither 
the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-
approve a total electric hospital bed.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says that the enrollee 
does not meet Medicare criteria for coverage of the SNF services. 
 
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 there 
is documentation that the enrollee requires daily skilled nursing services to safely and effectively provide 
medically necessary and reasonable treatment. Records document the need for daily complex wound care 
including wound treatments consisting of Iodosorb, crushed Flagyl, Dakins solution and Santyl with wounds up 
to stage 4 in severity. Our physician reviewer found there is documentation that the patient requires the services 
on an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 the sleep apnea pillow. 
 
You asked the Plan to pre-approve the sleep apnea pillow. You say that you feel that you may benefit from a 
CPAP pillow to resolve the symptoms. The Plan denied your request. The Plan says the requested pillow does 
not meet the definition of durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the sleep apnea pillow.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on November 1, 2021, billed 
with code 14041. 
 
You asked the Plan to pay for the services as billed. You say that the services were correctly billed and should 
be paid. The Plan denied your request. The Plan says code 14041 is not supported. 
 
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 14041 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 as billed. Our reviewer says that the services 
billed are not supported by the record. Our reviewer found Operative report describes undermining, to create 
flaps for wound closure. Operative report documents "First the distal skin wound edges were sharply debrided 
using scissors.  Next the wound measured 4 x 4 cm in dimension and was not amenable to primary complex closure.  First back-cut incisions were made using #5 blade in order to create 2 opposing skin flaps.  Skin flaps 
were then undermined and then rotated and advanced into the defect and reconstructed in Z plasty fashion.  The 
incision was then closed in layers.  At the conclusion of the repair there was good approximation of wound 
edges". According to our coder, this does not support the use of code 14041. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on November 1, 2021, billed with code 14041.
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 the SNF care. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare criteria for coverage of the SNF services. 
 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. Services in the 
home with home health care or in a long-term care facility on a part time basis appear 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 the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urological supplies. 
 
You asked the Plan to pre-approve the requested items. You say that the enrollee needs to self-catheterize to 
maintain proper urine flow. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that urological supplies are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records provided do not show that the enrollee has permanent 
urinary incontinence or retention. Based on this information, we decided that Medicare rules for coverage of 
the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve 
urological supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs care in an IRF, or his recovery 
will be set back. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been met. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for exacerbation of chronic obstructive lung disease. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller and accessories 
 
You asked the Plan to pre-approve the expandable controller and accessories. You say that you would like 
reconsideration because the requested accessories are medically necessary. The Plan denied your request. The 
Plan says the requested accessories are not medically necessary. 
 
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 expandable controller and 
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have 3 power options of tilt, recline, and power 
elevating leg rests but you do not need to control the power options through a joystick. Your upper extremity 
strength and function support that you can control any power options through your own switches. 
 
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 expandable controller and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the expandable controller and accessories
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for outpatient hospital services provided from 
October 20, 2021, to October 22, 2021. 
 
You asked the Plan to reduce the cost share for outpatient hospital services. You say that the Plan indicates 
your responsibility is $1,643.76 but the hospitals total amount due is only $1,424.78. You also say that it must 
be an error on the Plan's part. 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. Your 
contract with the Plan says that there is $300 deductible which applies to in-network outpatient hospital 
services, including outpatient surgery and lab services. The Plan contract also says that enrollees must pay 10% 
coinsurance after the deductible is met for in-network outpatient hospital services. The Plan applied $3.93 to the deductible for each lab service. The Plan also applied the remaining deductible of 
$64.65 to outpatient surgical services. After your deductible was applied, the remaining allowed amount was 
$15, 791.10 ($15,855.75 original allowed amount - $64.65 deductible = $15, 791.10 remaining allowed 
amount). The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 
deductible which applies to in-network outpatient hospital services, including outpatient surgery and lab 
services. This cost sharing is a contractual obligation that had not been met at the time outpatient hospital 
services was received on October 20, 2021, to October 22, 2021. 
You have also been asked to pay $1,579.11, which is 10% of the remaining allowed amount for the outpatient 
surgical services ($15,791.10 remaining allowed amount x 10% coinsurance = $1,579.11). You have been 
asked to pay a total of $1,651.62 (3.93 + 3.93 + 64.65 + 1579.11 = 1651.62). 
Outpatient hospital services fall within the Outpatient Hospital Services 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 outpatient hospital services provided from October 20, 2021, to 
October 22, 2021.