Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says that the enrollee 
does not require skilled nursing services on a daily basis. 
 
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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has new functional impairments with a change in clinical status that 
would require assessment by skilled nursing. Therefore, daily skilled services in a SNF are 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 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services provided were medically 
necessary. 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 March 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits and laboratory services on May 
5, 2022, to July 11, 2022. 
 
You asked the Plan to waive the copayment for office visits and laboratory services. You say that you would 
like to appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $65 
copayment per visit and a 50% coinsurance for office visits and laboratory services. The total cost share is 
$371.96. 
 
You have been asked to pay a $65 copayment per visit and a 50% coinsurance for office visits and laboratory 
services. This item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies and 
Physician/Practitioner services, including doctor's office visits benefit categories. 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 office visits and laboratory services on May 5, 2022, to July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says the requested injections do not meet the requirements for 
approval. Your request is not medically necessary because the enrollee's records do not have an MRI of the 
lumbar spine showing moderate-to-severe stenosis at L4-5. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of chronic low back pain with radiculopathy due to lumbar 
spondylosis. He has low back pain, and it is rated 6/10 and radiates to the left lower extremity. The pain 
interferes with activities of daily living and sleep. Treatment has included medical therapy, physical therapy, 
heat, a home exercise program, and chiropractic therapy. There is documentation of radiculopathy. The review 
has determined that the enrollee does not meet the LCD coverage criteria for the requested facet joint 
injections. The requested injections are not reasonable or medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 
cm provided to the enrollee on February 14, 2022. 
 
You asked the Plan to pay for the repair. You say that this should be paid for. The Plan denied your request. 
The Plan says the code is not appropriate for 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 13152 is "Repair, complex, eyelids, nose, ears and/or 
lips; 2.6 cm to 7.5 cm." 
 
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 repair. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that in this case, the record indicates that 
the enrollee underwent a procedure. The operative note documents dimensions of 1.1 x 1.2. x 2.5 cm.  The 
elements of the code's definition were not documented. 
 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 repair have not been met. Therefore, we decided that the Plan does not have 
to pay for repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm provided to the enrollee on 
February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (tumor of unknown origin), mRNA, gene 
expression profiling (81540) provided on July 1, 2022. 
 
You asked the Plan to pay for oncology gene expression profiling. You say that this test was medically 
necessary to obtain a diagnosis which is consistent with the enrollee's clinical presentation. The Plan denied 
your request. The Plan says this test is not medically necessary as it is unlikely to impact therapeutic decision-
making in the clinical management of this enrollee. 
 
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 pay for oncology gene expression profiling. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, there is no specific documentation indicating that the test 
results will result in clinical decision making for clinical management of the enrollee's condition. The review 
has determined that the items/services at issue in this case medically are not 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 oncology gene expression profiling have not been met. Therefore, we decided 
that the Plan does not have to pay for oncology (tumor of unknown origin), mRNA, gene expression profiling 
(81540) provided on July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay at the psychiatric hospital. 
 
You asked the Plan to pre-approve continued stay at the psychiatric hospital. You say that a continued stay at 
the psychiatric hospital is necessary. The Plan denied your request. The Plan says a continued stay is not 
medically necessary. Additional days are approved through 11/30/22 for consolidation of treatment gains and 
discharge planning. The enrollee is not suicidal or homicidal ideations with plan or intent, nor responding with 
hallucinations. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued stay at the psychiatric 
hospital. Our reviewer says that the service is not medically necessary. Our physician reviewer found the health 
plans denial of continued inpatient psychiatric services appears appropriate. The enrollee did not require 
inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself 
or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not 
present. It appears that the services were supervised and evaluated by a physician. Based upon review the 
records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of December 1, 2022, forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued stay at the psychiatric hospital have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued stay at the psychiatric hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a COVID-19 test provided on January 10, 2022. 
 
You asked the Plan to reimburse you for a COVID-19 test. You say that this test was ordered by a doctor. The 
Plan denied your request. The Plan says the Plan does not have a supplemental benefit that covers isolation or 
COVID-19 testing for the purpose of travel, so Medicare rules apply. According to the COVID-19 Frequently 
Asked Questions (FAQs) updated on 08/16/2022 on the Centers for Medicare & Medicaid Services website, 
Medicare does not cover COVID-19 testing solely for the purposes of travel. There is not an exception that 
would allow the plan to cover the cost of COVID-19 testing for the purpose of travel or for the hotel stay in 
Taiwan for the purpose of isolation. 
 
The Plan must follow Medicare rules.   
 
We looked at the file and Medicare rules. Medicare says that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. Therefore, we decided that the Plan does not have to reimburse you for a COVID-19 test provided on 
January 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional radiology services provided to the enrollee on 
April 16, 2022. 
 
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on the same date of 
service. The Plan denied your request. The Plan says this is either a component of a complete service that has 
already been paid, or it was the complete service for which a component has already been paid. 
 
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 70450 is "Computed tomography, head or brain; without contrast material." 
 
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 wer enot supported by the medical records. Our reviewer found that a review of the records shows two 
examinations done on 4/16/22. First, there was a computed tomography (CT) intracranial angiography done 
under accession # ending in 3827. This was followed by what labeled in the study header as CT intracranial 
angiography, accession # ending in 3829. However, this was actually a CT angiography of the neck. There is 
no support for two separate CT scan of the head/brain on this date. 
 
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 additional radiology services provided to the enrollee on April 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and lenses (V2100) following cataract 
surgery provided on March 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames and lenses. You say that you were not told what provider you could 
see. The Plan denied your request. The Plan says the eyeglasses are not covered because they were provided 
OON. The Plan also says that you were provided information about which providers are in-network. 
 
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 frames (V2020) and lenses (V2100) following 
cataract surgery provided on March 10, 2022, by an out-of-network (OON) provider.   
Your complaint about potentially not receiving information about network providers is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the heart (75571) 
provided on September 15, 2022. 
 You asked the Plan to pay for the CT scan of the heart. You say that your cardiologist requested that you get a 
calcium CT scan done in order to assess your cardiac risk due to significant family history of cardiac disease in 
combination with your own significant history of cardiac arrhythmia and present hyperlipidemia. The Plan 
denied your request. The Plan says benefits are not available for this service because it does not meet the Plan's 
medical technology assessment criteria or the medical policy guidelines for the procedure reported. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the CT scan of the heart, was requested solely for screening purposes due to 
your family history, rather than for treatment of any current disease. Medicare does not cover this test solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the computed tomography 
(CT) scan of the heart (75571) provided on September 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on July 01, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 each Medicare-covered Part B drug. Covered drugs include drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. The provider billed in the amount of $1,390.80 and the allowed amount is 
$1,275.60. $1,275.60 x 20% = $255.12. Therefore, results in the total cost sharing amount of $255.12. 
 
You have been asked to pay a 20% coinsurance for Part B drugs. This item/service 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 Part B 
drugs on July 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetes management training provided on March 31, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diabetes management training. You say that the services were medically 
necessary. The Plan denied your request. The Plan says authorization was not obtained prior to services being 
rendered. 
 
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 diabetes management training provided on March 
31, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 15, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 July 15, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot pressure off loading/supportive device (A9283) 
and a heel or elbow protector (E0191). 
 
You asked the Plan to pre-approve a foot pressure off loading/supportive device and a heel or elbow protector. 
You say that the wound on the enrollee's heel and diabetic ulcers of the ankle has ongoing lesions. The enrollee 
is being seen at the wound clinic. Progress notes from the 09/26/2022 visit for further processing has been 
submitted. The Plan denied your request. The Plan says a foot pressure off-loading/supportive device is not a 
covered benefit because it does not support a weak or deformed body member or restrict or eliminate motion in 
a diseased or injured part of the body, and the request for a heel or elbow protector is not a covered benefit 
because they do not meet the Medicare definition of a dressing, brace, or durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We looked at the file and Medicare rules. Specifically, the requested foot pressure supportive device and the 
heel or elbow protector are not listed as a covered benefit with the Plan. Based on this information, we decided 
that Medicare rules for coverage of a foot pressure off loading/supportive device and a heel or elbow protector 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a foot pressure off 
loading/supportive device (A9283) and a heel or elbow protector (E0191).