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

 
We decided that the Plan does not have to waive the copayments for the office visits (99213, 99214 x 2), the 
closure of a lacrimal punctum (68761 x 2), the injection(s), of an anesthetic agent and/or steroid, transforaminal 
epidural, with imaging guidance; lumbar or sacral, single level (64483), the injection(s), of a diagnostic or 
therapeutic agent, paravertebral facet joint (or nerves innervating that joint) with image guidance, lumbar or 
sacral; single level (64493), and the injection procedure for a sacroiliac joint, anesthetic/steroid, with image 
guidance including arthrography when performed (27096) provided from April 19, 2021, through  
December 21, 2021. 
 You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 physician specialist services (including surgery second opinion, telehealth, and urgently needed 
services).   
 
You have been asked to pay $360 ($40 copayment x 9) for the physician specialist services provided. 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 the office visits (99213, 99214 x 2), the closure of a 
lacrimal punctum (68761 x 2), the injection(s), of an anesthetic agent and/or steroid, transforaminal epidural, 
with imaging guidance; lumbar or sacral, single level (64483), the injection(s), of a diagnostic or therapeutic 
agent, paravertebral facet joint (or nerves innervating that joint) with image guidance, lumbar or sacral; single 
level (64493), and the injection procedure for a sacroiliac joint, anesthetic/steroid, with image guidance 
including arthrography when performed (27096) provided from April 19, 2021, through December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (27566 and 27405) provided on 
September 12, 2020. 
 
You asked the Plan to pay for codes 27566 and 27405. You say that the medical records support the billing of 
codes 27566 and 27405 provided on September 12, 2020. The Plan denied your request. The Plan says the 
medical records do not support the billing of codes 27566 and 27405 provided on September 12, 2020. 
 
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 27566 is Open treatment of patellar dislocation, with or 
without partial or total patellectomy. The definition of code 27405 is Repair, primary, torn ligament and/or 
capsule, knee; collateral. 
 
 
 We asked our coder 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 codes 27566 and 27405. Our reviewer says that the medical 
records do not support the billing of codes 27566 and 27405 provided on September 12, 2020. Our reviewer 
found codes 27566 and 27405 are not supported by the records. The operative note describes patella fracture 
fixation and not dislocation or tendon repair procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 27566 and 27405 have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (27566 and 27405) provided on September 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the calibrator solution/chips rendered on August 18, 2021 to 
November 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the calibrator solution/chips rendered on 
August 18, 2021 to November 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on November 23, 
2021 to December 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled Nursing Facility services. You say that the services provided were 
medically necessary. 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 Skilled Nursing Facility services provided on 
November 23, 2021 to December 8, 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 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. 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 an office visit provided on February 1, 2022 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 subsequent nursing facility care rendered on April 16, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 subsequent nursing facility care rendered on April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 26, 2020, to August 31, 2020. 
 
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 provider has reported skilled services with the incorrect Patient Driven Payment Model 
(PDPM) Health Insurance Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, the provider billed a PDPM score of FDGC1. The plan disagrees with the fourth alphanumeric 
character, C. The 4th alphanumeric character - C - represents a non-therapy ancillary (NTA) score of 6-8, with 
diagnoses of ulcerative colitis, Crohn's disease, or inflammatory disease, plus multi-drug resistant organism, 
diabetes mellitus, morbid obesity, and malnutrition/risk for malnutrition. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported in the medical records. Our reviewer found the enrollee had listed diagnoses on 
the (unsigned) Physician Order Report from 8/10/20 through 9/17/20 that include rhabdomyolysis (primary), 
enterocolitis, acute embolism and thrombosis, pneumonia, and morbid obesity. The records do not show a 
diagnosis of ulcerative colitis, Crohn's disease, or inflammatory bowel disease in the 60 days before the SNF 
stay, or as an active diagnosis during the SNF stay. Additionally, the records do not show a diagnosis of 
malnutrition or risk of malnutrition in the 60 days before the SNF stay, or as an active diagnosis during the 
SNF stay. Finally, the records do not show a diagnosis of morbid obesity as a diagnosis in the 60 days before 
the SNF stay, or as an active diagnosis during the SNF stay. The unsigned order report cannot be used to 
confirm this diagnosis. 
 
We looked at this coder's review, the file, and Medicare rules. A review of the records confirms that a NTA 
score of 6 is not supported in this case. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility (SNF) services provided to the enrollee from August 26, 2020, to August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CGM provided on December 28, 2021. 
 
You asked the Plan to waive the coinsurance for CGM. You say that the enrollee cannot afford the monthly 
charge for the glucose monitor. The Plan denied your request. The Plan says the coinsurance 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% for in-network, Medicare-covered equipment, and supplies.  
 
The enrollee has been asked to pay $51.94, which is 20% of the allowed amount for the CGM. The allowed 
amount is $259.72 (20% x $259.72 = $51.94). The CGM falls within the Durable medical equipment (DME) 
and related supplies benefit category. 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 coinsurance for 
CGM provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on March 8, 2022. 
 
You asked the Plan to pay for chiropractic treatment. The Plan denied your request. The Plan says only cover 
manipulation of spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic treatment provided on March 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter drainage rendered on November 8, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that payment for post-operative services is included in the 
global surgical package.  
 
We looked at the file and Medicare rules. Billed procedure code 49406 (image-guided fluid collection drainage 
by catheter) was billed within 10 days of minor surgical procedure 10160 (puncture aspiration of abscess, 
hematoma, bulla, or cyst), performed on November 4, 2021. Payment for code 49406 is included in the global 
surgical package of the original procedure. Therefore, we decided that the Plan does not have to pay for the 
catheter drainage rendered on November 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 27, 2021, to December 3, 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 enrollee does not require daily skilled nursing services such as the administration of IV 
antibiotics, management and education of a new PEG tube or colostomy, or complex wound care. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the patient required skilled nursing or skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse or qualified therapist were not required to safely and 
effectively provide medically necessary and reasonable treatment from 09/27/2021 through 12/03/2021. The 
records did not document the need for intravenous medications, new tube feeding or ostomy care or daily 
complex wound care. Daily skilled services were not provided or required. This patient did not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear 
custodial in this case from 09/27/2021 through 12/03/2021. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 27, 2021, to 
December 3, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 25, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not 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. In this case, we have confirmed that code 99283 
is a column II code to column I code 99222. 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 emergency room (ER) services rendered on October 25, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 1, 2018, and  
February 22, 2019. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the claim was not 
received by the Plan within 12 months or 1 calendar year from the date when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until September 28, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on December 1, 2018, and February 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 5, 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 billed correctly. 
 
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 these 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 the laboratory services rendered on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services provided on 
November 30, 2021 and December 2, 2021. 
 
You asked the Plan to waive the copayments for chiropractic services. You say that you are appealing the 
copayments applied. 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 $20 in-
network copayment for Medicare-covered chiropractic services at a specialist's office.  
 
 You have been asked to pay a $20 copayment for the chiropractic services. Chiropractic services fall within the 
Chiropractic 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 
chiropractic services provided on November 30, 2021 and December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 25, 
2021, to October 28, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the patient met criteria for inpatient 
admission. The Plan denied your request. The Plan says inpatient hospital admission was not medically 
necessary because there was no documentation in the medical records showing that the patient was expected to 
require hospitalization for more than two midnights. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record does not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights. The patient's chest pain resolved by the 
time of admission, and his electrocardiogram (EKG) and cardiac enzymes were normal. Although the duration 
of the hospitalization lasted greater than two midnights, the medically necessary components (serial EKG, 
serial cardiac enzymes, echocardiogram, cardiology consultation) should have been able to be completed with a 
time period of less than two midnights. Inpatient admission was not 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 25, 2021, to October 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 December 22, 2021 by 
an out-of-network (OON) provider.