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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he/she is not currently 
receiving but that would be available at the LTACH facility. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy (CPT code 90837) to be provided by a 
mental health counselor. 
 
You asked the Plan to pre-approve psychotherapy. You say that you have been seeing this provider for at least 
a year and a half and they are very familiar with your background and issues. You state that you feel 
comfortable having sessions with the provider. The Plan denied your request. The Plan says outpatient mental 
health treatment with a licensed mental health counselor (LMHC) is not a covered benefit. The Plan states 
Medicare could pay for counseling provided by an enrolled licensed clinical social worker, psychologist, or 
psychiatrist. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of psychotherapy have not been met. Outpatient mental health 
treatment with a LMHC is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve psychotherapy (CPT code 90837) to be provided by a mental health counselor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on September 1, 2021, by an 
OON provider. 
 
You asked the Plan to pay for outpatient surgery. You say that the provider is in-network and no authorization 
was required. You say that the severity of the care provided was medically necessary and should be covered. 
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 outpatient surgery provided on September 1, 2021, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on February 21, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that services should be covered under the 
authorization number the facility received. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan. The Plan also says that authorization was not obtained prior to the 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 ophthalmological services provided on February 
21, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on June 2, 
2021. 
 
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required 
information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the submitted documentation does not include a current proof of deliver or a tracking form for the 
billed code. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand 
orthosis provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on August 16, 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 Plan must follow Medicare rules. The rules say that for claims involving third party liability, the agency 
must reject the claim and return it to the provider for a determination of the amount of liability. 
 
We looked at the file and Medicare rules. The file shows that the services were covered under a workers' 
compensation claim. Payment for these services is the responsibility of that claim. Therefore, we decided that 
the Plan does not have to pay for the office visit rendered on August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
March 11, 2022, to March 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you think this should be 
covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $318 
copayment per day for days 1 through 7. $0 additional copayment for days 8 through 90.  
 
You have been asked to pay $2,226 (7 days x $318) copayment for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for inpatient hospital stay provided from March 11, 2022, to March 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 lab 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 lab services provided on November 16, 2021.
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 skilled nursing facility (SNF) services. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the skilled nursing 
facility (SNF) services you are requesting do not meet the requirements for approval. 
 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 skilled nursing facility (SNF) services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found after careful 
review; I agree with the denial of skilled nursing facility (SNF) services. This beneficiary does not meet 
severity of illness or intensity of service criteria for 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 skilled nursing facility (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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely 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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing visit provided from February 6, 2022, to 
March 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a skilled nursing visit. You say that your office called to verify benefits on 
February 10, 2022, and spoke with a representative of the Plan. You also say the representative from the Plan 
informed you that no precertification was required and that you were in-network. The Plan denied your request. 
The Plan says the records show that the national provider identifier (NPI) number provided on the call your 
office made was for the referring provider, who is in-network, and not your facility. The Plan also says that the 
enrollee has access to in-network home health agencies within 10 miles of her address. 
 
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 skilled nursing visit provided from February 6, 
2022, to March 7, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
June 30, 2021 to July 22, 2021 
 
You asked the Plan to pay for the heating pad. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says the requested device does not meet the 
definition of DME per Medicare guidance. 
 
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 pay for the water circulating heat pad with pump (E0217) provided June 
30, 2021 to July 22, 2021
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from June 7, 2021, to 
June 30, 2021. 
 
You asked the Plan to waive the copayment for SNF care. You say that you didn't ask to be there those 4 days 
so it should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $125 
copayment for days 1 through 20 and $125 copayment for days 21 through 100 of your stay.  
 
You have been asked to pay $500 (4 days x $125) copayment for SNF care. SNF care falls within the Skilled 
Nursing Facility (SNF) 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 SNF care 
provided from June 7, 2021, to June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 CGM (CPT code K0553). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 shows that the enrollee takes fixed dose insulin 
twice a day and does not adjust their insulin dose in real time based on their blood glucose results. Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G6 CGM (CPT code K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on November 
12, 2020, to November 13, 2020. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you already paid $275 and 
dont think you should have to pay the rest. You dont react well to anesthesia and knew you would have to 
spend the night. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $350 
copayment for certain procedures done at outpatient hospital facility. 
 
 
 
 
 You have been asked to paya total of $350 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery provided 
on November 12, 2020, to November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis provided on March 23, 2022. 
 
You asked the Plan to pay for the shoulder orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the claim on file was requested by a provider exam that was not 
conducted in person. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder 
orthosis provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that this item is medically necessary for your 
condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules state that a mastectomy sleeve (L8010) is denied as 
noncovered, since it does not meet the definition of a prosthesis. Based on this information, we decided that 
Medicare rules for coverage of a mastectomy sleeve have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a mastectomy sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies including disposable diapers and 
disposable under pads. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies including 
disposable diapers and disposable under pads.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (CPT code(s): 20680, 21465, 21470) 
provided on March 9, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the claim should be paid. 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. 
 
Our records show the dentist rendered procedure code 20680 78 on date of service January 19, 2022. Per the 
CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) File procedure 20680 performed on 
January 19, 2022, has a global surgery value of 090 This is a major procedure that has a global surgery period 
of 90 days. This is a major procedure that has a global surgery period of 90 days. Procedure codes 21470 and 
20680 billed on date of service March 9, 2022, are included within the global surgery package of procedure 
20680-78 billed on date of service January 19, 2022. Per CMS, a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between procedure code 21465 and 21470. This PTP edit has a 
modifier indicator of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier 
was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the surgical 
services (CPT code(s): 20680, 21465, 21470) provided on March 9, 2022.