Persius/hicric huggingface dataset:
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care.  You 
are walking household distances with a rolling walker with supervision and is supervision to modified 
independent for transfers. Provided records do not document a significant decline in your functional status to 
necessitate daily inpatient skilled therapy services. You do not require the services on an inpatient basis, only in 
a skilled nursing facility setting. Records do not document those services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate in this case. 
 
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 coinsurance for Surgery on January 27, 2022. 
 
You asked the Plan to waive the coinsurance for surgery. You say that you want to appeal the amount being 
charged. 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 20% 
coinsurance for surgery performed at an Outpatient Hospital Facility. The Plan allowed the amount of 
$5,721.91. $5,721.91 x 20% = $1,144.38. Therefore, results in the total cost-sharing amount of $1,144.38.  
  
You have been asked to pay a 20% coinsurance for surgery. 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 coinsurance for Surgery on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 7, 2021, to 
September 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this provider is an in-network provider. The 
Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also 
says that the services were not referred by a network provider or rendered in a participating facility. 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 laboratory services provided on September 7, 
2021, to September 23, 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 hospital care services provided on December 15, 2021. 
 
You asked the Plan to pay for hospital care services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number 
on claims for items/services provided in clinical trials/studies/registries, or under coverage with evidence 
development (CED). 
 
 
  We looked at the file and Medicare rules. In this case, the services at issue were provided under a CED clinical 
trial. The claim at issue did not include the appropriate clinical trial number. Based on this information, we 
decided that Medicare rules for coverage of hospital care services have not been met. Therefore, we decided 
that the Plan does not have to pay for hospital care services provided on December 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 6, 2021, and October 20, 
2021. 
  You asked the Plan to pay for psychotherapy. You say that the information proves the medical necessity of the 
services provided and payment should be arranged. The Plan denied your request. The Plan says the provider 
must attempt to consult the attending or primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
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. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on October 6, 2021, and 
October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of uterus through abdomen, and exploration of 
abdominal cavity (hysterectomy). 
 
You asked the Plan to pre-approve the surgery. You say that your monthly menstrual cycle is often painful. The 
Plan denied your request. The Plan says you may qualify for coverage if documentation is received that states 
the imaging was negative for endometrial lesions. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that your physical examination was notable for no cervical motion tenderness, normal size non-tender 
uterus, and no parametrial tenderness or mass, and no adnexal tenderness or mass. The clinical documentation 
does not support that the enrollee in this case has an indication for hysterectomy that is medically reasonable 
and necessary. The documentation does not support that the enrollee has intractable pelvic pain. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal of uterus through abdomen, and exploration of abdominal cavity (hysterectomy).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on December 30, 
2021, and December 31, 2021. 
 
You asked the Plan to pay for critical care services (99291). You say that the documentation supports the 
evaluation and management level of care billed and the codes are payable as billed. You say that the denial 
should be reviewed. The Plan denied your request. The Plan says the documentation submitted did not support 
a critical care visit of 30-74 minutes was performed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document 
the time spent on critical care services as required by the CPT code billed. Based on this information, we 
decided that Medicare rules for coverage of critical care services (99291) have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99291) provided on December 30, 2021, 
and December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered on March 16, 
2022. 
 
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 criteria for coverage are not met. 
 The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered for 
melanoma stage T1a or above. 
 
We looked at the file and Medicare rules. The records show that the enrollee has stage zero (0), in situ, disease. 
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 DecisionDx-Melanoma testing rendered on 
March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition, endo skeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an addition, endo skeletal knee-shin system, stance flexion feature, 
adjustable (L5845), an addition to endo skeletal knee-shin system, fluid stance extension, dampening feature, 
with or without adjustability (L5848) and an addition to lower extremity prosthesis, endo skeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s) (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested prosthetics are medically necessary. 
The Plan denied your request. The Plan says that the request exceeds the enrollee's need and does not meet the 
Medicare criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee owns a landscaping business and it is clear that the enrollee expects to participate 
in exercise beyond simple locomotion when he returns to work. The enrollee's risk of fall and injury is 
reasonably expected to be lowered by the requested microprocessor knee and foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an addition, endo skeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), 
an addition, endo skeletal knee-shin system, stance flexion feature, adjustable (L5845), an addition to endo 
skeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) and 
an addition to lower extremity prosthesis, endo skeletal knee-shin system, microprocessor control feature, 
swing and stance phase, includes electronic sensor(s) (L5856).  
 
 
 
 
 
 
 
 
 
 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 waive the copayment for a specialist office visit provided on March 
10, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you keep being told over 
the phone that you owe money. You also say that you are not receiving any invoices  to verify what you owe, 
or what you owe it for so that you can make a payment plan. The Plan denied your request. The Plan says you 
were 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 $35 
copayment per visit with a specialist.  
 
 
 
 
 
 You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services, including doctor's office visits 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 specialist office visit provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor (CGM) sensors 
(K0553) billed for date of service December 11, 2021. 
 
You asked the Plan to pay for CGM sensors. You say that the items at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
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. Specifically, the 
documents in the case record provided as proof of delivery do not correspond to the billed date of service. Therefore, we decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor 
(CGM) sensors (K0553) billed for date of service December 11, 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. You 
are walking household distances with a rolling walker with contact guard assistance and is contact guard assist 
for transfers. Provided records do not document a significant decline in your functional status to necessitate 
daily inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Records do not document those services in the home with home health care or in a 
long-term care facility on a part time basis are not appropriate in this case. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on October 4, 
2021, to November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that the enrollee lives at a state 
veterans nursing facility. You say you have a contract with this nursing home to check all defibrillators and 
have a medical liability to provide this service. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 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 did not pre-approve the 
interrogation device evaluation. We found no exception that would require the Plan to pay for the interrogation 
device evaluation. The records provided for review do not show that the interrogation device evaluation was 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the interrogation device 
evaluation provided on October 4, 2021, to November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a magnetic resonance imaging 
(MRI) of the brain stem provided on January 26, 2022. 
 
You asked the Plan to waive or reduce the copayment for the MRI. You say that you were not aware of the 
copayment and you cannot afford it. 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 $325 
copayment for each diagnostic radiology service other than CT scans.  
 
You have been asked to pay $245.84, which is less than the $325 copayment for the MRI. The MRI 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 or reduce the copayment for a magnetic resonance imaging (MRI) of the brain stem 
provided on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
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 indicates that the enrollee does not use insulin 
with at least three daily injections and 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 a Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for new patient office visit (99203) established 
patient office visit (99213) provided June 17, 2021 to December 31, 2021. 
 
You asked the Plan to waive the copayment for the office visits. You say that you were referred by your 
primary care physician to see a rheumatologist. You were requested at the doctor's office and submitted a 
copay of $40 for each visit. You noticed your share for both visits was $0.00 and you would like restitution for 
these payments. The Plan denied your request. The Plan says the claim was processed with the correct cost 
share per the Evidence of Coverage. 
 
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 $40 
copayment for specialist's office visits.  
 
You have asked for reimbursement of $80.00 for the office visits. The office visits fall within the 
Physician/Practitioner services, including doctor's office visits 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 new patient office visit (99203) established patient office visit (99213) provided 
June 17, 2021 to December 31, 2021.