Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient nail debridement services on 
January 13, 2022. 
 
You asked the Plan to waive the copayment for nail debridement. You say that the enrollee is requesting 
reconsideration because he states that he did not have surgery/operation, or an ingrown toenail removed. He 
went to have his toenails cut. The Plan denied your request. The Plan says a $400 copayment for outpatient 
surgery, including services provided at hospital outpatient facilities and a $350 copayment for ambulatory 
surgical center. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $400 copayment for in-network outpatient surgery services.  
 
 
 The enrollee has been asked to pay $65.29, which is less than the $400 copayment for nail debridement. Nail 
debridement falls within the in-network outpatient surgery services. The enrollee has a $400 copayment for 
outpatient hospital and a $350 copayment for ambulatory surgical center. The total charged amount of $101.00 
and plan paid $35.71. The allowed amount on this claim is $65.29. The enrollee is being held responsible for 
the lesser amount. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient nail debridement 
services on January 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital the 
member had stabilized medically. The member did not require any skilled nursing or rehab services on a daily 
basis at an inpatient level of care. He was not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care tasks. 
The member did not require skilled therapy to establish a safe and effective maintenance program. As a 
practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at 
the time of discharge from the hospital. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism (E0627), provided on February 8, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the item should be covered. The Plan 
denied your request. The Plan says you obtained this item through an out-of-network supplier. 
 
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 seat lift mechanism (E0627), provided on 
February 8, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee-shin system. 
 
You asked the Plan to pre-approve the requested prosthesis. The Plan denied your request. The Plan says that 
there is no objective clinical documentation to corroborate the enrollee requires the requested system. 
 
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.  
 
The file shows that an adjustable endoskeletal knee-shin system, stance flexion feature, coded as L5845 was 
requested. 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 requested prosthesis. Our 
physician reviewer found that the enrollee has a past medical history of left above the knee amputation and 
right foot partial amputation. Authorization for L5845 an additional knee feature is being requested. The 
provider has attested to the information documented by CPO including functional level and appropriateness of 
L5845 thus this additional knee feature is medically necessary. 
 
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 requested prosthesis have been met. Therefore, we decided that the Plan has 
to pre-approve a knee-shin system.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) Scan on 
March 3, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) Scan. You say that you 
would like to appeal the cost share. 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 a $275 
copayment for a computerized tomography (CT) Scan.  
 
You have been asked to pay a $275 copayment for a computerized tomography (CT) Scan. A computerized 
tomography (CT) Scan 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 computerized tomography (CT) Scan on 
March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 1, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the service performed by the non-participating provider 
was not authorized by the Plan and was not referred by a participating provider. 
 
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 subsequent nursing facility care provided on 
November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you have had 
colonoscopies every 3 years without a charge. You say that this time you owe $290. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 $290 
copayment for each Medicare-covered in-network outpatient hospital facility visit.  
 
 
 
 
 You have been asked to pay a $290 copayment for a diagnostic colonoscopy. The diagnostic colonoscopy falls 
within the Outpatient surgery 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 
diagnostic colonoscopy provided on December 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 10, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee was not given a 
room and was treated poorly during the stay. The Plan denied your request. The Plan says the enrollee was 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay $365 per day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
 
 The file shows that the enrollee was in the hospital from December 10, 2021, to December 14, 2021, but there 
is no copayment for the discharge date. Therefore, the enrollee was asked to pay $365 per day for the first 4 
days of inpatient care. The total for the stay is $1,460 ($365 copayment x 4 days = $1,460). The inpatient care 
falls within the Inpatient Hospital Care benefit category. This means that the enrollee was asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided from December 10, 2021, to December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye specialist visit provided on February 
10, 2022. 
 
You asked the Plan to waive the copayment for the eye specialist visit. You say that you made an appointment 
due to eye irritation following an exam the day before. 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 $45 
copayment for each visit with an eye specialist.  
 
You have been asked to pay a $45 copayment for the eye specialist visit. The eye specialist visit falls within the 
Vision 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 an eye specialist visit 
provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are submitting documentation for 
review of the denied claim. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you requested to be 
taken to the ER due to lack of care. 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 $225 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
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 copayment for 
ambulance transportation provided on November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from December 8, 2019, 
through December 10, 2019, at DRG 896. 
 
  You asked the Plan to pay for the inpatient services at DRG 896. You say that G92 is a valid secondary 
diagnosis code for this admission and the medical record clearly documents the diagnosis of toxic 
encephalopathy. You say that the coding is supported and DRG 896 is correct. The Plan denied your request. 
The Plan says G92 is not substantiated as a valid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code G92 defined as toxic 
encephalopathy. 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 pay for the inpatient services at 
DRG 896. Our reviewer says that the documentation does not support the diagnosis code of G92. Our physician 
reviewer found that there was no other condition aside from alcohol abuse, which caused the altered mental 
status. The listing of encephalopathy in the medical record is not supported by the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from December 8, 2019, through December 10, 2019, at DRG 896.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 23, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11720 
is a column II code to column I code 11055. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for surgical services provided to the enrollee on September 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychosocial rehabilitation services to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the psychosocial rehabilitation services. You say that you have seen this 
provider before, and they provide different activities that help you. The Plan denied your request. The Plan says 
the requested provider is an OON provider, and a list of multiple in-network providers was given to the 
enrollee that provide the same quality 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 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 psychosocial rehabilitation services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an eyelid repair procedure performed on 
February 9, 2022. 
 
You asked the Plan to reduce the copayment for the eye surgery. You say that you were informed your 
copayment would only be $275. 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 $350 
copayment for surgery or services provided at an outpatient hospital.  
 
You have been asked to pay a $350 copayment for the eye surgery. The eye 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 reduce the copayment for an eyelid repair procedure performed on 
February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care provided on March 25, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for initial observation care provided on March 25, 
2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on February 7, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on February 7, 2022.