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

 
We decided that the Plan does not have to pre-approve transfer to a SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 the enrollee does not qualify for SNF 
coverage.  The enrollee does not have documented skilled nursing needs. The enrollee does 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 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transfer to a SNF care.
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 the enrollee requires SNF care. The Plan denied 
your request. The Plan says the enrollee does not require the daily skilled therapy or nursing services required 
to qualify for a 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that 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 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 waive the cost share for the office visit provided on January 19, 2021. 
 
You asked the Plan to waive the cost share for the office visit. You say that you are in a lot of pain and couldnt 
see your provider because you had an outstanding balance that needs to be paid. The Plan denied your request. 
The Plan says that the coinsurance applied correctly but Medicaid paid the coinsurance 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 enrollees pay a $0 copayment for provider and professional services at an in-
network PCPs office or specialists office.  
 
The Plan applied $3.06 toward your deductible and 20% coinsurance for the office visit. Based on the Plan 
contract, however, you cannot be asked to pay more than $0 for the office visit. The Plan contract does not list 
a deductible amount and clearly says that you pay $0 for office visit. This means that $3.06 toward your 
deductible and 20% coinsurance should not have been applied to the office visit. Therefore, we decided that the 
Plan has to waive the cost share for the office visit provided on January 19, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit (99236) provided on July 22, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that since the member was in a nursing 
facility, the doctor was not responsible to get authorization. You also say the nursing home was responsible to 
obtain prior authorization for their patients. The Plan denied your request. The Plan says an authorization was 
not obtained prior to the services being rendered, and the provider is not participating with the Plan. The Plan 
also says that it was determined the services were not urgent or emergent in nature. 
 
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 domiciliary or rest home visit (99236) provided on 
July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 1, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken.  POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions and implant services provided from June 29, 
2021, to September 17, 2021. 
 
You asked the Plan to pay for the extractions and implant services. You say that you were told the Plan would 
pay on the surgery to remove all of your teeth. You also say that the surgery you had was not elective, and you 
were told all of your teeth were rotting below the gum line. The Plan denied your request. The Plan says 
extractions and implants are not covered under the dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extractions and implant services provided from June 29, 2021, to September 17, 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 the enrollee needs SNF care. The Plan denied your 
request. The Plan says there is no documentation of the need for inpatient skilled nursing or therapy, or daily 
skilled 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 daily 
skilled services are not necessary. Our physician reviewer found that 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgeries provided on August 31, 2021, 
and September 29, 2021. 
 
You asked the Plan to waive the copayment for eye surgeries. You say that you want your copayment back 
because you already paid it to the provider. You also say that after having problems with your medication and 
having issues with the provider you stopped going to that office. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient surgery at an ambulatory surgical center.  
 You have been asked to pay a total of $300, which is a $150 copayment for each eye surgery ($150 copayment 
+ $150 copayment = $300). Eye surgeries falls within the Outpatient Surgery, Including Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for eye surgeries provided on August 31, 2021, and September 29, 2021.  
 
Your complaint about the amount of time the provider spends with patients 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transportation services (A0430-GZ, 
A0435-GZ) provided on August 13, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that these services were provided in good 
faith and believe these services were medically necessary. The Plan denied your request. The Plan says these 
services were billed with the GZ modifier, and therefore are excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that items and services 
that are not medically necessary are not covered. 
 
We looked at the file and Medicare rules. The services in this case were billed with a GZ modifier, which by 
definition means that these services do not meet the criteria for Medicare coverage. The provider in this case is 
not contracted with the Plan, and the Plan does not have the authority to change the submitted claim. Medicare 
rules state that items submitted with a GZ modifier shall be denied automatically and will not be subject to 
complex medical review. Based on this information, we decided that Medicare rules for coverage of the air 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air 
ambulance transportation services (A0430-GZ, A0435-GZ) provided on August 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for psychotherapy telehealth services 
provided on October 7, 2021, and November 1, 2021. 
 
You asked the Plan to waive the copayments for the psychotherapy telehealth services. You say that  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 $30 
copayment for each telehealth mental health visit.  
 
The file shows that the Plan had reprocessed the claims to reflect the correct copayment amounts. Therefore, 
you have been asked to pay a $30 copayment for each visit for the psychotherapy telehealth services. The 
psychotherapy telehealth services fall within the Outpatient Mental Health Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for psychotherapy telehealth services provided on October 7, 2021, and 
November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services (75716, 75726) 
 
You asked the Plan to pay for the angiography services. You say that these services have been coded correctly 
and should be paid. The Plan denied your request. The Plan says the documentation does not support payment 
for the services 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, the CPT Code Manual definition of code 75716 is angiography, extremity, bilateral, radiological 
supervision and interpretation. The CPT Code Manual definition of code 75726 is angiography, visceral, 
selective or supraselective (with or without flush aortogram), radiological supervision and interpretation. We find that CPT code 75716 and 75726 are not supported in the medical record. Specifically, according to 
Local Coverage Article A57056 the billed primary diagnosis of S30.1XXA is not supported as a billable 
diagnosis for the rendered services 75716 and 75726. Based on this information, we decided that Medicare 
rules for coverage of the angiography services have not been met. Therefore, we decided that the Plan does not 
have to pay for the angiography services (75716, 75726)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the claim to be paid. The 
Plan denied your request. The Plan says the rendering and referring providers are both out-of-network 
providers and there was no referral from the enrollee's primary care physician. Also, the service rendered was 
not urgent or emergent. 
 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 10, 2021, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 4, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that POS code 81 is correct for this testing. 
The Plan denied your request. The Plan says the POS code reported does not match the location where the 
sample was taken. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to get an 
approved authorization and it was medically necessary for the physician to see the enrollee. The Plan denied 
your request. The Plan says the rendering provider is an out-of-network provider and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on October 18, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 14, 
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 provider did not bill as required by Medicare coding regulations. 
 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 imaging services provided to the enrollee on September 14, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary pathogen testing provided on October 19, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says this testing was not authorized and was ordered and performed by OON 
providers 
 
 
 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, nor is the ordering provider. 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 urinary pathogen 
testing provided on October 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 24, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship 
between the enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 24, 2021.