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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
1, 2022, to January 2, 2022. 
 You asked the Plan to pay for SNF care. You say that these services were necessary and should be paid. The 
Plan denied your request. The Plan says SNF care was not medically necessary for the enrollee on the dates in 
question. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that based on the medical records provided, 
there is no documentation that the enrollee required skilled nursing services that required the specialized skill, 
knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary 
and reasonable treatment for these dates. Records did not document the need for intravenous medications, new 
tube feeding, ostomy care or daily complex wound care. Based on the records provided, the enrollee did not 
require and did not receive skilled therapy services which required the specialized skill, knowledge and 
judgement of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment. The services provided on the dates in question appear to be custodial in this case, and therefore the 
SNF services were not medically reasonable and 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) care provided from January 1, 2022, to January 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 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 of the 
denied claim. 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 January 5, 2022 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for hallux ridigus correction surgery provided 
on January 13, 2022. 
 
You asked the Plan to reduce the cost share for hallux ridigus correction surgery. You say that you received a 
call from the hospital's billing department informing you that your expense would be around $400. You also 
say you are retired and on a fixed income. 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. Your 
contract with the Plan says that there is $450 deductible which applies to outpatient surgery at an outpatient 
hospital. The Plan contract also says that the enrollee must pay 10% coinsurance for outpatient surgery at an 
outpatient hospital. 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $956.57 for the hallux ridigus correction surgery on January 13, 2022. The deductible was not met at 
the time of service; therefore, $132.35 was applied to satisfy the remainder of the deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $450 deductible which applies to 
outpatient surgery at an outpatient hospital. This cost sharing is a contractual obligation that had not been met 
at the time the hallux ridigus correction surgery was received on January 13, 2022.  
 
The allowed amount remaining after you paid your deductible is $8,242.22 ($8,374.57 original allowed amount 
- $132.35 deductible paid = $8,242.22 remaining allowed amount). You have been asked to pay $824.22, 
which is 10% of the remaining allowed amount for the hallux ridigus correction surgery ($8,242.22 remaining 
allowed amount x 10% coinsurance = $824.22). Hallux ridigus correction 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 cost share for hallux ridigus correction surgery provided on 
January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen dressing, sterile (A6021) gauze, impregnated, sterile 
(A6223) specialty absorptive dressing, wound cover, sterile (A6252) gauze, non-impregnated, sterile (A6402) 
conforming bandage (A6446) provided on January 6, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound supplies. You say that you received this referral from a provider that 
is contracted with the Plan. This is referred to as plan directed care. Therefore, you believe the in-network 
requirement has been satisfied. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for collagen dressing, sterile (A6021) gauze, 
impregnated, sterile (A6223) specialty absorptive dressing, wound cover, sterile (A6252) gauze, non-
impregnated, sterile (A6402) conforming bandage (A6446) provided on January 6, 2022 by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient care. The Plan denied your request. The Plan says you will not 
require a greater than 2 midnight stay. 
 
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 pre-approve inpatient care. Our physician reviewer 
found that you have primary osteoarthritis of the right shoulder. This is a request for inpatient services related 
to an approved elective, nonemergent total shoulder arthroplasty. The provided documentation describes you as being preoperatively cleared without any evidence of an unstable 
condition or circumstances that would expect hospital care. There was insufficient support made in the 
documentation that the patient required hospital care that would likely cross 2 midnights for this typically 
ambulatory procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient hospital services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy (PT) services provided on 
February 24, 2022. 
 
You asked the Plan to waive the deductible for the PT services. You say that this was a very high charge for the 
service. The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Rehabilitation 
Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $750 deductible which applies to certain items and services. This cost sharing is a contractual obligation that 
had not been met at the time the PT services were received on February 24, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for physical therapy (PT) services provided on February 24, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can receive the care she needs in another setting. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility is not equipped 
for all of your needs. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute 
care and do not require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not already available at the current 
facility. Our reviewer found that there are no services at the LTACH that you require that are not already 
available and covered at the current facility. Our physician reviewer also found that transfer to LTACH is not 
medically necessary as it would not be clinically advantageous at this 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Otto Bock C-leg 4 microprocessor knee and extra 
rotation for foot. 
 
You asked the Plan to pre-approve the Otto Bock C-leg 4 microprocessor knee and extra rotation for foot. You 
say that the items are medically necessary. The Plan denied your request. The Plan says the requested items 
exceed the members needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Otto Bock C-leg 4 microprocessor 
knee and extra rotation for foot. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found the documentation provided by the medical provider does not support that the enrollee is a K3 ambulator and therefore the advanced components are 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 the Otto Bock C-leg 4 microprocessor knee and extra rotation for foot have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Otto Bock C-leg 4 
microprocessor knee and extra rotation for foot.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued admission in a skilled nursing facility 
(SNF). 
 
You asked the Plan to pre-approve a continued SNF admission. You say that you do not want to leave the SNF. 
The Plan denied your request. The Plan says your request for a continued admission in SNF does not meet the 
requirements for approval. 
 
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 a continued SNF admission. Our 
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continued SNF admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continued admission in a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hyperbaric oxygen therapy provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for hyperbaric oxygen therapy. You say that you were given the 
wrong information on how much you would be charged. 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 $175 
copayment for outpatient hospital services.  
 
You have been asked to pay $100 copayment, which is less than the standard $175 copayment for hyperbaric 
oxygen therapy.  Hyperbaric oxygen therapy falls within the Outpatient hospital 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 hyperbaric oxygen therapy provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exam and refraction you had on October 7, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers refractions when provided during a routine vision exam. 
 
We looked at the file and the Plan's rules. The requested refraction was provided during a medical vision exam, 
not a routine vision exam. The Plan only covers refractions provided during routine exams. Additionally, the 
medical vision exam you had requires a $35 copayment. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay 
for the exam and refraction you had on October 7, 2021.
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 procedure is medically necessary. 
The Plan denied your request. The Plan says this 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services rendered from November 9, 2021 to 
November 17, 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 that the submitted records do not support the billing of procedure codes 0J9B0ZZ and 
0KBP0ZZ. 
 
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 provided with procedure codes 0J9B0ZZ and 0KBP0ZZ. 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 these services. Our reviewer says that the 
submitted records support the billing of procedure codes 0J9B0ZZ and 0KBP0ZZ. Our physician reviewer 
found the enrollee presented to the emergency department (ED) on November 9, 2021 with sores on the left hip 
and buttocks. He was evaluated and admitted. He had a left hip abscess and sacral ulcers. He was placed on 
intravenous (IV) antibiotics and underwent debridement of the hip and sacral wounds. A wound vacuum was 
placed on the left hip wound. The records support the billing of procedure codes 0J9B0ZZ and 0KBP0ZZ. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services rendered from November 9, 2021 to November 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 2, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service February 2, 
2022.