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

 
We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission beginning December 
19, 2021 forward. 
 
You asked the Plan to pre-approve SNF care. You say that there is no economical way that the intensity of 
therapy you have been receiving could be provided by home health care services. The Plan denied your request. 
The Plan says that the records available do not show that inpatient daily skilled nursing or therapy services 
were medically necessary to improve your functional abilities. 
 
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 admission is medically reasonable and necessary. Our physician reviewer found you qualified for 
SNF coverage at the time of admission. You did not have documented skilled nursing needs. You do have 
documented skilled therapy needs. You were functioning below the baseline. You have not been shown to have 
reached a new plateau in function. Daily skilled services were reasonably required to establish a maintenance 
program or to prevent deterioration of your 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 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 a skilled 
nursing facility (SNF) admission beginning December 19, 2021 forward.  
 
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 lab services provided on July 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services should be paid. The Plan denied 
your request. The Plan says you billed this claim with an incorrect Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS). In this case, you billed with POS 81, but 
it appears as though the sample was taken from the patient in an office setting.   This would mean that POS 11 should have been reported on the claim. 
 
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. Therefore, we decided that the Plan does not have to pay for lab 
services provided on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81210, 81275, 81276, 
81292, 81295, 81298, 81301, 81311, 81317, 81194 and 81309) provided on April 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 the laboratory services have not been met. CPT codes: 81210, 
81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81194 and 81309 (1 Units) remains not supported. 
The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen 
was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 
81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in an Inpatient Hospital setting POS 21. Also, the laboratory results submitted indicate the specimen 
was collected on February 24, 2021, and received by the lab on March 24, 2021; therefore, the billed code 
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81210, 
81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81194 and 81309) provided on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance treatment without transport 
provided on May 17, 2021, and May 20, 2021. 
 
You asked the Plan to waive the copayments for the ambulance treatment. You say that you feel that you 
should not be charged for the treatments since you did not go to the hospital. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each ambulance stabilization when there is no transport.  
 
You have been asked to pay a $250 copayment for each ambulance treatment, for a total of $500. The 
ambulance treatment falls within the Ambulance 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 waive the copayments for ambulance treatment without transport provided on May 
17, 2021, and May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, ankle (73610) radiologic 
examination, foot (73630) provided on October 27, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic service. You say that please review all medical records showing 
the exam was medically necessary. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before 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 radiologic examination, ankle (73610) radiologic 
examination, foot (73630) provided on October 27, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 23, 2020. 
 
You asked the Plan to pay for the lab services. You say that you believe that this claim was denied due to a 
signature issue. The Plan denied your request. The Plan says you billed these lab services with an incorrect 
Place of Service (POS). 
 
The Plan must follow Medicare rules. Medicare rules say that f an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS). In this case, you billed with POS 81, 
which would indicate that you physically collected the sample from the patient in an independent lab facility.  However, the records show that the specimen was collected from the patient in their skilled nursing facility, so 
that is the POS that should have been billed on the claim. 
 
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. Therefore, we decided that the Plan does not have to pay for lab 
services provided on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alginate or other fiber gelling dressing, wound cover (CPT 
code A6197) provided on September 28, 2021. 
 
You asked the Plan to pay for the item. You say that there were two A6197. The Plan denied your request. The 
Plan says the item is not covered as billed. 
 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 the item have not been met. CPT code A6197 is assigned a status 
code P = Bundles/excluded codes. There are no RVUs, and no payment amounts for these services. No 
separate payment is made for them under the fee schedule. As the claim was billed with a CPT code which is 
always bundled; We find that Medicare rule for payment of this claim has not been met. If the provider 
determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a 
submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not 
have to pay for alginate or other fiber gelling dressing, wound cover (CPT code A6197) provided on September 
28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on November 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99140, 99100) provided October 27, 
2020. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99140, & 99100 is not supported in the medical record. Specifically, the codes billed 
have a status of "B" per the National Physician Fee Schedule and payment is bundled into payment for a 
primary service.  
 
 Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not 
been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99140, 99100) 
provided October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you are appealing this denial and the service is 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit to be provided 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 telehealth services rendered on February 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 performed.
The Plan must follow Medicare rules. The rules say that providers/suppliers have an obligation, under law, to
conform to the requirements of the Medicare program.
We looked at the file and Medicare rules. The file shows that the there is no evidence that the billed services
were performed. Based on this information, we decided that Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for the telehealth services rendered on
February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on October 14, 2021. 
 
You asked the Plan to waive the copayment for the wound care. You say that the wound was caused by a fall at 
the hospital and you should not be responsible for the treatment. 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 $260 
copayment for surgery or other services provided to you at an outpatient hospital.  
 
 
 You have been asked to pay $179.08, which is less than the $260 copayment for the wound care. The wound 
care 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 wound care 
provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visits. You say that you need to start radiation for prostate cancer and the network provider is over 100 miles away. The Plan denied your request. The Plan says the provider is out-of-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided 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 service (CPT code 81479) provided on July 
20, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 the laboratory service have not been met. CPT code 0242U 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an outpatient hospital POS 22. Of note, the patient resides in Colorado and 
the billing laboratory is located in Illinois; therefore, the billed code, the validity and accuracy of the claim 
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided 
on July 20, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the clinical trial services (CPT code(s): G6002, 77336, 77427, 77523) 
provided on July 27, 2021. 
 
You asked the Plan to pay for the clinical trial services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that they should be the third payer for this claim and the Plan cannot process this 
claim until they have received payment information from the primary and secondary payers. 
 
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 the clinical trial services have been met. Review of the file shows 
that Original Medicare paid, applying 20% coinsurance so $285.77. The plans EOC shows that they cover 
pretty much everything in full. Since everything is $0, that means that the Plan has to pay the entire amount left 
after the Medicare payment. Therefore, we decided that the Plan has to pay for the clinical trial services (CPT 
code(s): G6002, 77336, 77427, 77523) provided on July 27, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular stress test provided on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for the stress test. You say that the provider quoted you a $135 
copayment. 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 $275 
copayment for non-radiological diagnostic tests, including stress tests.  
 
You have been asked to pay $258.06, which is less than the $275 copayment for the stress test. The stress test 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a cardiovascular stress test provided on November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eyelid revision surgery provided on 
September 17, 2021. 
 
You asked the Plan to waive the copayment for eyelid revision surgery. You say that botox injections caused 
your eyelids to droop requiring the surgery. You also say that the surgery was medically necessary. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery at an outpatient hospital.  
 
You have been asked to pay a $250 copayment for eyelid revision surgery. Eyelid revision 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 eyelid revision surgery 
provided on September 17, 2021.  Your complaint about the doctor not talking to you and the nurse being rude 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve Wegovy. The Plan denied your request. The Plan says Wegovy is self-
administered and not covered as a Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wegovy.  
 
 
 Benefits for Wegovy may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.