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

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not require daily skilled nursing or rehabilitation services as of 
the last covered day. The enrollee was at or near their prior level of function and can be discharged to a lower 
level of care for further 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on October 10, 2022. We 
also decided that the Plan does not have to waive the cost share for the nuclear medicine heart study provided 
on October 10, 2022.  
 
You asked the Plan to waive the cost share for the nuclear medicine heart study and drug injection. You say 
that you received prior approval for these services. The Plan says that this cost sharing was charged correctly. We decided that the Plan has to waive the coinsurance for the drug injection.  
 
You have been asked to pay 20% coinsurance for the drug injection. According to Medicare, the injection 
(code J2785) is considered a packaged code and is not separately payable. This code is also excluded from the 
physicians free schedule. Therefore, we decided that the Plan has to waive the cost share for the drug injection 
provided on October 10, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the nuclear medicine heart 
study. 
 
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 $375 
copayment for in-network diagnostic radiology, including nuclear medicine.  
 
You have been asked to pay a $375 copayment for the nuclear medicine heart study. This item/service falls 
within the outpatient diagnostic tests and therapeutic 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 nuclear medicine heart study provided on October 10, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the drug injection provided on September 12, 2022. 
We also decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
September 12, 2022.  
 You asked the Plan to waive the copayments for the drug injection and specialist office visit. You say that this 
was charged as two procedures. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
We decided that the Plan has to waive the copayment for the drug injection.  
 
You have been asked to pay $17.76, which is less than the standard $20 copayment for the drug injection. 
According to Medicare, the injection (code J1030) is considered a packaged code and is not separately payable. 
This code is also excluded from the physicians free schedule. Therefore, we decided that the Plan has to waive 
the copayment for the drug injection provided on September 12, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the specialist office visit. 
 
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 $10 
copayment for the specialist office visit.  
 
You have been asked to pay a $10 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 specialist office visit provided on September 12, 2022. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing.  
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services from October 13, 
2021, through October 19, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you have attached the proof of timely filing 
which substantiates that the initial claim was submitted to the payer on time. The Plan denied your request. The 
Plan says you must complete billing, including resolving all claim discrepancies within 12 months of the date 
of service. 
 
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 SNF services was not filed until January 18, 2023. 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 skilled nursing facility (SNF) services from October 13, 2021, through 
October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on October 
04, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care visits provided on October 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112 billed for date of service December 1, 
2022. 
 
You asked the Plan to pay for procedure code 88112. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 88112 is bundled into 
payment for code 88173. 
 
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 88112 
is a column II code to column I code 88173. 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 88112 billed for date of service December 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies, wipes. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration because 
the requested incontinence supplies are medically necessary. The Plan denied your request. The Plan says the 
requested incontinence supplies are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, wipes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on October 
18, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care visits provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
Gastroenterologist. 
 
You asked the Plan to pre-approve office visits to be provided by an OON Gastroenterologist. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plan says they have equally qualified 
in-network Gastroenterologist's available to you that can provide the services you are requesting. The Plan has 
confirmed that you have not seen the OON provider since 2019. 
 
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 
office visits to be provided by an out-of-network (OON) Gastroenterologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on December 
06, 2022. 
 
You asked the Plan to pay for principal care management services. You say that you have no prior knowledge 
of who you would be seeing. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for principal care 
management services provided on December 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denial as the CGM is a 
medical necessity. You also say when you test your fingers swell up and start throbbing and it is extremely 
painful. The Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity. 
 
You asked the Plan to pre-approve an MRI of the lower extremity. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says an 
MRI of the lower extremity is not medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lower extremity. Our 
reviewer says that the requested MRI of the lower extremity is not medically necessary. Our physician reviewer 
found that aside from the bilateral normal knee radiographs done in 2022 there were no medical records that 
included a physical exam. There is no evidence of any red flags that will need an immediate MRI without a 
trial of physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an MRI of the lower extremity.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you require additional physical therapy before being 
discharged because your spouse is unable to assist you at home. The Plan denied your request. The Plan says 
the SNF services requested do 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You 
are able to walk and are toilet independent (modified). Your functional status does not require daily skilled 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you had additional teeth break and need 
new dentures to be able to eat. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 4, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5212).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LDCT scan. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee has chronic obstruction 
disease and has never smoked. You say that the enrollee is compliant with medication. The Plan denied your 
request. The Plan says a LDCT scan in not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. 
 
We reviewed the file and the Medicare rules. We find that the enrollee has no smoking history. Therefore, we 
decided that the Plan does not have to pre-approve a LDCT scan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the member needs rehabilitation and moderate to 
maximum monitoring. The Plan denied your request. The Plan says the SNF services requested do 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. The enrollee has not regained neurological function sufficient to respond to therapy. He 
requires continued support but has inability to respond to daily skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from December 10, 2022, to 
December 12, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says inpatient care was no longer needed after December 9, 2022. 
 
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 pay for the inpatient care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found no worsening or new acute symptoms were reported nor were any procedures done that 
required inpatient admission. The enrollee remained in the hospitalized for disposition planning. 
 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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient hospital care provided from December 10, 2022, to December 12, 2022.