Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 13, 2022, to 
January 27, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
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 diagnosis code J96.01. 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 hospital services at the DRG originally billed. Our 
reviewer says that the submitted records do not support the billing of diagnosis code J96.01. Our physician 
reviewer found the enrollee presented to the emergency department on January 13, 2022 as unresponsive. She 
did not have labored respirations and her oxygen saturation was 85 percent on room air and she responded to 
three liters of oxygen. She was evaluated by Neurology and her diagnosis was a major neurocognitive disorder 
with behavioral disturbances. There is no documentation acute respiratory failure. Diagnosis code J96.01 is not 
supported by the submitted records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 13, 2022, to January 27, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the MI Tumor Seek molecular diagnostic testing provided on July 25, 
2022. 
 
You asked the Plan to pay for the MI Tumor Seek testing. You say that this is medically necessary testing that 
has been covered by Medicare since 2016. The Plan denied your request. The Plan says that based on the LCD 
rules, this is not a covered test because it is not approved or cleared by the Food and Drug Administration 
(FDA). 
 
Please note: We have disregarded the Plans denial rationale in this case because the rules do not limit 
coverage only to FDA-approved or cleared testing.  
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The molecular diagnostic testing provided in this case is listed as 
Medicare-covered in the DEX database. No valid denial rationale was provided by the Plan, and no information 
regarding the network status of the ordering physician was included in the file. Based on this information, we 
decided that Medicare rules for coverage of the MI Tumor Seek testing have been met. Therefore, we decided 
that the Plan has to pay for the MI Tumor Seek molecular diagnostic testing provided on July 25, 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: Unfavorable

 
We decided that the Plan does not have to pay for code 99213 billed for dates of service March 24, 2022, to 
March 31, 2022. 
 
You asked the Plan to pay for code 99213. You say that you have a contract to have these services paid. The 
Plan denied your request. The Plan says this code is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that odes with a status indicator of B are not 
recognized by OPPS (Outpatient Prospective Payment System) when submitted on an outpatient hospital Part 
B bill.  In this case, you billed code 99213 on an outpatient hospital Part B bill.  However, code 99213 has a 
status indicator of B, meaning that it is not recognized for payment on an outpatient hospital bill.  An alternate 
code must be used instead.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99213 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99213 billed for dates of service March 24, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71260 and 76376 billed for date of service 
May 23, 2022. 
 You asked the Plan to pay for procedure codes 71260 and 76376. You say that you do not believe that these 
services should be bundled. The Plan denied your request. The Plan says payment for codes 71260 and 76376 
is bundled into payment for codes71275. 
 
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 codes 
71260 and 76376 are column II codes to column I code 71275. Code pair 71275 and 71260 has a modifier 
indicator of 1, meaning that separate payment is possible if an appropriate billing modifier is also billed. This 
claim has not been billed with an appropriate modifier to bypass the edit. For code pair 71275 and 76376, this 
pair has a modifier indicator of 0, meaning that no modifiers are allowed. 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 codes 71260 and 76376 billed for date of service May 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Pembrolizumab (Keytruda) is not FDA 
approved for the treatment of ovarian cancer. Use is not supported by the medical literature or major drug 
compendia. There are no markers just as tumor mutational burden (TMB), microsatellite instability (MSI) or 
Measles, Mumps & Rubella (MMR) provided to indicate support from molecular markers to support use. The 
service is not reasonable or 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 30, 2022 and 
May 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 in this case, the enrollee was admitted in stable condition and there was not a 
reasonable expectation that the care would need to span 2 or more midnights. The 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 April 30, 2022 and May 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services with anesthesia provided to the enrollee on 
April 6, 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 denied codes remain not supported. 
 
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 01210: 
 
Anesthesia for open procedures involving hip joint; not otherwise specified 
 
CPT 64447: 
 
Injection(s), anesthetic agent(s) and/or steroid; femoral nerve 
 
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 01210, the 
procedure report describes anesthesia services for total hip arthroplasty (THA), in this case there is a more 
specific code that should be reported for service provided. For CPT 64447, the primary procedure code for 
anesthesia cannot be verified; therefore, the anesthetic agent injection would not be covered, as this is a coding 
conflict with anesthesia services. 
 
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 injection services with anesthesia provided to the enrollee on April 6, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a bone mass measurement exam provided on August 
24, 2022. 
 
You asked the Plan to waive the copayment for a bone mass measurement exam. You say that you believe the 
cost share should be waived because you have not had a bone density exam in 4 years, and you were told it was 
fully covered. The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing 
information (such as copayments, deductibles and coinsurance).   
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan charged a copayment for a specialist visit; however, CPT codes 77080 
and 77089 are not office visit codes. The contract says that bone mass measurements do not have a copayment 
unless there are additional non-preventive services performed. The Plan has not substantiated their denial, as 
they have not sent any medical records to show if additional services beyond the bone mass measurement were 
rendered. There is no way to verify if additional non-preventive services were rendered. Therefore, we decided 
that the Plan has to waive the copayment for a bone mass measurement exam provided on August 24, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950), and crown - full cast high noble metal tooth #15 (D2790). 
 
You asked the Plan to pre-approve the core buildup, including any pins when required (D2950), and crown - 
full cast high noble metal tooth #15 (D2790). The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
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. The Plan covers the core 
buildup, including any pins when required (D2950), and crown - full cast high noble metal tooth #15 (D2790) 
when the services are medically necessary and reasonable.   
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 core buildup, including any pins 
when required (D2950), and crown - full cast high noble metal tooth #15 (D2790). Our reviewer says that the 
documentation provided was not sufficient to meet the criteria for coverage for a core build-up (D2950) and a 
crown restoration (D2790) for tooth #15. Our physician reviewer found the photographs provided were of poor 
quality and a determination for the need for a crown rather than a restoration could not be established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the core buildup, including any pins when required (D2950), and crown - full 
cast high noble metal tooth #15 (D2790) have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a core buildup, including any pins when required (D2950), and crown - full cast high noble 
metal tooth #15 (D2790).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is a medical necessity. The 
Plan denied your request. The Plan says the request for coverage for admission to a LTACH is not medically 
necessary. 
 
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 the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 
 
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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested allogeneic cellular tissue-
based injection is considered experimental in nature. More research is needed to show its safety and efficacy. 
The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 18, 2022, to 
February 16, 2022. 
 
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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 18, 2022. The NOA was not received by the Plan until November 
19, 2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from January 18, 2022, to February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet coverage criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you  
require this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mesalamine. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mesalamine.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require intensive or complex rehabilitation. No indication for frequent 
physiatry oversight.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.