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

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are requesting authorization for SNF 
admission with medical records. The Plan denied your request. The Plan says the enrollee's needs can be met 
with intermittent physical and occupational three to four times per week. the enrollee's needs are largely 
custodial at this time. The enrollee's care needs can be provided in a lower level of care setting, such as with 
home health services. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found based on the documentation 
provided, it is their opinion that 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. The enrollee 
is ambulating more than 100 feet. The enrollees care needs, custodial and intermittent, can, as a practical 
matter, be provided at a lower level of care such as home health services, assisted living, or long-term 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this drug is medically reasonable The 
Plan denied your request. The Plan says the requested procedure is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit provided. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan 
also says that they have also determined that these services are not urgent or emergent, nor were they approved 
in advance. 
 
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 an office visit provided on February 1, 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 continuous positive airway pressure (CPAP) device 
received on January 31, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that all network providers were backed up due to a 
machine recall. The Plan denied your request. The Plan says the item is not a covered benefit when provided 
from a non-Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device received on January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral surgery services provided on December 27, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for oral surgery services. You say that the out-of-network periodontist was the only 
one in the area to use. The Plan denied your request. The Plan says the oral surgery services received were 
rendered by a non-participating provider, without an authorization, and will not be covered. 
 
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 oral surgery services provided on December 27, 
2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
January 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee has no out-
of-network benefits. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 
28, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for psychotherapy on January 04, 2022, to 
March 15, 2022. 
 
You asked the Plan to waive the copayments for psychotherapy. You say that you were not aware that the 
copays were not being waive any more due to covid. The Plan denied your request. The Plan says the cost-
sharing you are being charged 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 a $40 
copayment for each individual/group therapy visit with another mental health care professional. Covered 
services include: Mental health services provided by a state-licensed psychiatrist or doctor, clinical 
psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other 
Medicare-qualified mental health care professional as allowed under applicable state laws. There were 6 visits, 
resulting in a total copayment amount of $240. 
 
 You have been asked to pay a $40 copayment for each psychotherapy. Psychotherapy falls 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 on January 04, 2022, to March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say to please utilize the medical records provided in regard to 
the enrollee's visit. 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 a home visit provided on December 18, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre. 
 
You asked the Plan to pre-approve Freestyle Libre. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of Freestyle Libre have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Freestyle Libre.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81455) provided on August 17, 
2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says genetic testing procedures submitted 
with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services (81455) 
provided on August 17, 2021, have been met. In this case, no medical records have been submitted from the 
enrollees ordering provider to indicate the medical necessity of the ordered testing.  Therefore, we decided that 
the Plan does not have to pay for the genetic testing services (81455) provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) colonography (74263). 
 
You asked the Plan to pre-approve a CT colonography. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested study is not covered for screening 
purposes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography (CT) colonography (74263).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (64447, 64445) provided February 2, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 64447, & 64445 is not supported in the medical record. Specifically, the laterality 
attached to the procedure codes does not match the laterality of the diagnosis codes. Based on this information, 
we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided 
that the Plan does not have to pay for surgical services (64447, 64445) provided February 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by an out-
of-network (OON) provider from October 18, 2021, to October 20, 2021. 
 
You asked the Plan to waive the copayment for the OON inpatient care. You say that you had to be monitored 
for infection. You say that you also met your maximum out-of-pocket expenses for the year. 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 $360 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were in the hospital from October 18, 2021, to October 20, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $360 per day for the first 2 days of 
OON inpatient care. The total for your stay is $720 ($360 copayment x 2 days = $720). Please note that while 
your maximum out-of-pocket (MOOP) expenses were met, only in-network services apply. In this case, the 
provider is out-of-network, and the copayment does not apply to your MOOP. The OON inpatient care 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 care provided by an out-of-network 
(OON) provider from October 18, 2021, to October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve monitored anesthesia care for a colonoscopy. 
 
You asked the Plan to pre-approve monitored anesthesia care for a colonoscopy. You say that you have had 
two colonoscopies with polyps removed with anesthesia in the past and you feel like having another 
colonoscopy without anesthesia will be too painful. The Plan denied your request. The Plan says there is no 
medical necessity for anesthesiologist monitored anesthesia. 
 
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 monitored anesthesia care for a 
colonoscopy. Our reviewer says that monitored anesthesia care for a colonoscopy is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the available records do not support 
that your clinical condition is of a complexity or severity, nor that your planned colonoscopy is of a complexity 
or anticipated procedural duration to warrant as medically appropriate nor necessary monitored anesthesia care. 
You have tolerated conscious sedation previously. Conscious sedation is appropriate for your planned 
colonoscopy at this point in time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of monitored anesthesia care for a colonoscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve monitored anesthesia care for a colonoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your copayments for radiation therapy visits from August 10, 
2021, to August 31, 2021. 
 
You asked the Plan to waive your copayments for radiation therapy visits from August 10, 2021, to August 31, 
2021. You also asked the Plan to waive your copayment for your physical therapy session on August 11, 2021.  
You say that you should not have to pay these copayments. The Plan denied your request. The Plan says you 
pay a $60 per day copayment for radiation therapy visits. The Plan also says you pay a $40 copayment for each 
physical therapy visit. 
 
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 $60 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. 
 
You have been asked to pay a $60 copayment for each radiation therapy visit from August 10, 2021, to August 
31, 2021. Radiation treatments fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. You have also been asked to pay a $40 copayment for a physical therapy session on 
August 11, 2021. Physical therapy sessions fall within the Outpatient Rehabilitation 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 your copayments for radiation therapy visits from August 10, 2021, to August 
31, 2021. We also decided that the Plan does not have to waive your copayment for a physical therapy session 
on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 16, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that the provider's office did not advise you that the 
provider was not in-network when you provided your ID card. The Plan denied your request. The Plan says the 
non-contracted provider did not obtain prior authorization prior to the date of service. 
 
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 office visit provided on March 16, 2022, by an 
out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided by an out-of-
network (OON) provider from November 3, 2021 to December 17, 2021. 
 
You asked the Plan to pay for durable medical equipment (DME). You say that you need the items you 
purchased. 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 durable medical equipment (DME) provided by an 
out-of-network (OON) provider from November 3, 2021 to December 17, 2021.