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

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary as 
the enrollee needs daily therapy. The Plan denied your request. The Plan says that the 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 the 
requested SNF care is medically reasonable and necessary. Our physician reviewer found that based on the 
documentation provided, the enrollee qualifies for SNF coverage. The enrollee does not have documented 
skilled nursing needs, though monitoring of her vital signs, pain level and surgical incision are reasonable. The 
enrollee does have documented skilled therapy needs. The enrollee is functioning below her baseline. The 
documentation does not yet establish that the enrollee has reached a new plateau in function. The enrollee is at 
risk for falls and further injury. A period of daily skilled services is medically necessary and reasonable to 
establish a maintenance program and/or to prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says the enrollee's needs are non-skilled in nature. 
 
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 SNF 
care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery and injection services provided on January 10, 2022, 
to March 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that you were not aware that there was an 
out-of-network maximum benefit.  You said that you were not given all of the information when you enrolled 
in the Plan. The Plan denied your request. The Plan says you exhausted your OON benefit. 
 
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. You also have a Point of Service (POS) benefit).  According to 
your contract, this benefit covers some services you get with out-of-network providers.  The POS benefit for 
out-of-network covered services is 30% coinsurance.  There is a POS plan coverage limit of $3000 per calendar 
year.  Once this limit is reached, you are responsible for 100% of the cost of out-of-network services. 
 
In this case, you have already exhausted your $3000 annual benefit for out-of-network care under the POS 
benefit.  This limit is clearly disclosed in your Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for surgery and injection services provided on January 10, 2022, to March 14, 2022, by an out-
of-network (OON) provider.  
 
Your complaint about not being advised about the POS benefit limit during enrollment is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6196, A6212) provided on February 
3, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they were 
non-emergent and prior authorization was not 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 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 wound care supplies (A6196, A6212) provided on 
February 3, 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 subsequent hospital care provided on January 7, 2022, to 
January 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital care. 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 
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 subsequent hospital 
care provided on January 7, 2022, to January 9, 2022, 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 the debridement of toenails (11720) 
performed on March 29, 2022. 
 
You asked the Plan to waive the copayment for nail debridement. You say that you paid for two services out of 
pocket that should have been charged to your insurance. You say those are fraudulent charges on your account. 
The Plan denied your request. The Plan says the cost-share was properly applied according to your contract. 
 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 
copayment for each visit of Medicare-covered podiatry services and non-Medicare covered routine care.  
 
You have been asked to pay a $20 copayment for nail debridement. Nail debridement falls within the podiatry 
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 the debridement of toenails 
(11720) performed on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and destruction procedures on benign or 
premalignant lesions of the integumentary system provided on March 15, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for an office visit and destruction procedures on benign or premalignant lesions of 
the integumentary system. You say that the claim was processed incorrectly with the facility national provider 
identifier (NPI) and not the rendering provider as it should. The Plan denied your request. The Plan says the 
provider is not in-network and there is no authorization on file. 
 
 
 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 and destruction procedures on 
benign or premalignant lesions of the integumentary system provided on March 15, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a sleep apnea (c-pap) machine provided 
from April 4, 2022, to May 4, 2022. 
 
You asked the Plan to waive the coinsurance for a c-pap machine. You say that you should not have a 
coinsurance for this item, and that it is too costly. The Plan denied your request. The Plan says the coinsurance 
applied was 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 durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$353.84 resulting in a coinsurance amount of $70.77 ($70.77 x 2 = $141.54). 
 
You have been asked to pay a total of $141.54 coinsurance for a c-pap machine. A c-pap machine falls within 
the Durable Medical Equipment (DME) and Related 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 coinsurance for a sleep apnea (c-pap) machine provided from 
April 4, 2022, to May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on July 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that the referring physician is in-network. The Plan 
denied your request. The Plan says the referring physician and rendering provider are out-of-network, and the 
services were not 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 the lab testing provided on July 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 cystourethroscopy and related services (procedure codes 
52335, 51720) provided to the enrollee on September 10, 2021.  
You asked the Plan to pay for the services. You say that the records support the billing was done correctly. The 
Plan denied your request. The Plan says procedure code 52235 is not supported by the medical records 
submitted. The Plan also says procedure code 51720 is included in procedure code 52235 and cannot be 
separately reimbursed. 
 
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 the denied codes is: 
 
CPT 52235: 
 
cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM 
bladder tumor(s) (2.0 to 5.0 cm) 
 
CPT 51720: 
 
bladder instillation of anticarcinogenic agent (including retention time) 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 52235, the 
procedure report does not include documentation of cystourethroscopy with fulguration. In terms of CPT 
51720, the procedure report does not verify cystourethroscopy, with fulguration has been performed, in which 
Medium bladder tumor resection would be inclusive to. In this case, the tumor resection includes 
cystourethroscopy with fulguration. The denied codes cannot be verified. 
 
We looked at this coder'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 cystourethroscopy and related services (procedure codes 52335, 51720) provided to the enrollee 
on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82728, 83540, 83550) provided on 
January 17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that there is no agreement in place to include these 
services in the dialysis rate. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82728, 83540, 
83550) provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for knee injections on January 18, 2022, to 
February 01, 2022. 
 
You asked the Plan to waive the copayment for knee injections. 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 $0 
copayment or $275 copayment for each Medicare-covered outpatient hospital facility visit. $0 copayment for 
any surgical procedures (i.e., polyp removal) during a colorectal screening. $275 copayment for all other 
Outpatient Services not provided in an Ambulatory Surgical Center. Note: If you are having surgery in a 
hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. 
Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay 
the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be 
considered an outpatient. There were 3 visits, resulting in the total amount of $825. Therefore, results in the total cost-sharing amount of 
$825.  
 
You have been asked to pay a $275 copayment for each knee injections. Knee injections fall 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 copayment for knee injections on January 18, 
2022, to February 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor 
provided to the enrollee on January 18, 2022. 
 
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 date of service does not match the date that the items were shipped or delivered. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) supplies must 
be provided with a proof of delivery. 
 
The date of service and the shipped/delivered date do not match 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 a supply allowance for a continuous glucose 
monitor provided to the enrollee on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 9, 
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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 drug testing services provided to the enrollee on July 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the endoscopy on September 16, 2021. 
 
You asked the Plan to waive the deductible for the endoscopy. You say that it was processed incorrectly, and 
you are requesting that the claim be reprocessed and to assist with receiving the overpayment back from the 
provider. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to Outpatient hospital services.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time the endoscopy was received on September 16, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for the endoscopy on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility discharge services provided on  
January 22, 2022. 
 
You asked the Plan to pay for nursing facility discharge services. You say that your physician provided 
medically necessary services in good faith. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless authorized by the Plan before the services are provided. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nursing facility discharge services provided on January 22, 2022.