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

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services received under hospice provided to the enrollee 
from August 26, 2021, to September 2, 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 Original Medicare should be billed. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for services received under hospice provided to the enrollee from 
August 26, 2021, to September 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97163) provided on September 
21, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to 
the services of a physician/NPP also must meet all incident-to requirements. 
 
We find that CPT code 97530 is not supported in the record. Specifically, the record shows that this claim was 
billed by a nurse practitioner and the services were rendered by a physical therapist. A nurse practitioner cannot 
bill for the services of a Physical Therapist. Therefore, we decided that the Plan does not have to pay for the 
physical therapy services (97163) provided on September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 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 the provider did not bill as required by Medicare coding regulations. 
 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 76700 
is a column II code to column I code 93976. 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 imaging services provided to the enrollee on November 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided 
September 22, 2021 to November 1, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that it is of the most importance to your 
mental health that you are able to see this provider. This service is of the utmost importance to your mental 
health as well as physical. The Plan denied your request. The Plan says the services were rendered by an 
ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services 
(90837) provided September 22, 2021 to November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided July 1, 2021. 
 
You asked the Plan to pay for the hospital services. You say that resubmitting the claim with medical records 
attached. Please review for payment. The Plan denied your request. The Plan says this service exceeds the 
allowed discharge per stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management, more than 
30 minutes.  
We find that CPT code 99239 is not supported in the medical record. Specifically, the records show 99239 was 
processed and paid to another provider. Only the attending physician of record reports the discharge day 
management service. Based on this information, we decided that Medicare rules for coverage of the hospital 
services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge 
day management services (99239) provided July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services billed with codes D1999, D0460, D0364, and 
D0140 you received on September 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are angry that these dental services were 
not covered. The Plan denied your request. The Plan says these services are not covered under your dental 
benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services billed with codes D1999, D0460, D0364, and D0140 you received on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient domiciliary, rest home visit (99336) 
provided on September 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary, rest home visit. You say that the enrollee has no choice in the 
medical professionals they are seen by while in the facility. You rely on the facility to obtain any necessary 
authorizations when your providers are asked to see patients at their facility. 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 the established patient domiciliary, rest home visit 
(99336) provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 
30, 2021, to May 29, 2021. 
 You asked the Plan to pay for the SNF care. You say that the SNF services provided from April 30, 2021, to 
May 29, 2021, were medically necessary. The Plan denied your request. The Plan says the enrollee did not 
meet criteria for the SNF services provided from April 30, 2021, to May 29, 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not support that it was 
medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of 
these services) daily on an inpatient basis, in a skilled nursing facility 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 the 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 April 30, 2021, to May 29, 2021.
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 enrollee meets criteria for IRF services and 
cannot be managed at a lower level of care. The Plan denied your request. The Plan says the enrollee can be 
managed at a lower level of care. 
 
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 o acute therapy or nursing needs have been identified or documented in the record. The enrollee is medically stable and does not need physician supervision 3 times per week (at a minimum) for 
the ongoing management of any active or acute exacerbations of chronic medical conditions. At the current 
functional level, the enrollee needs in-home or skilled nursing facility level of therapies, and the enrollee does 
not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. IRF admission is not medically necessary based on lack 
of medical complexity and lack of acute rehab nursing needs and high functional status. The enrollee's needs 
can be met safely at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with 
therapies. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 2, 2021 to January 8, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says secondary diagnosis G93.43 was removed from the claim, consistent with the 
documentation that was submitted. 
 
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.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found 
metabolic encephalopathy was coded on January 6, 2021 and January 7, 2021 throughout this hospital stay; 
however, the documentation does not include a clear and consistent course of treatment for this condition. The 
1/6 documentation states "Mild metabolic encephalopathy. seems to be improving I will review her medical 
therapies." There is no other documentation included addressing this condition. Metabolic encephalopathy is 
not documented in the discharge summary. This diagnosis should be queried before reporting.  
 
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 to the enrollee from January 2, 2021 to January 8, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have complex care needs that require a coordinated team approach. 
 
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 documentation does not support that the enrollee requires at least 3 hours a 
day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. The documentation supports that 
services can be provided at a lower level of 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on October 16, 
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 due to the absence of the required medical documentation, this service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, billing this code twice is 
considered duplicate billing. There is no evidence given that this was a separate service. 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 radiology services provided to the enrollee on October 16, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the WATS 3D brush biopsy provided to the enrollee on August 5, 
2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the available record notes a history of high grade dysplasia in the setting of Barrett's, and the high 
likelihood of Barretts esophagus recurrence. This meets the spirit of ASGE guidance relative to medically 
necessary use of WATS-3D in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the WATS 3D brush biopsy provided to the enrollee on August 5, 2020.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 1, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. 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 ultrasound services provided to the enrollee on November 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D brush biopsy provided to the enrollee on June 
10, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records did not include an esophagogastroduodenoscopy (EGD) report, nor indication of the same, 
and as such does not support the high likelihood of Barrett's esophagus. As such, the record as provided does 
not meet the spirit of ASGE guidance relative to medically necessary use of WATS-3D in this case.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the WATS 3D brush biopsy provided to the enrollee on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 16, 2020, to December 23, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has 
reported inpatient hospital services with the incorrect DRG. 
 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.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
medical records do not validate sepsis as a primary diagnosis, due to unclear and inconsistent documentation. 
Throughout the entire hospital stay, sepsis was listed once as a secondary diagnosis for metabolic 
encephalopathy. The emergency department, subsequent hospital care and hospital discharge summary all 
support the care and treatment of facial cellulitis, treated with antibiotics, and negative blood cultures, and new 
onset of atrial fibrillation treated. Of note, the discharge summary does not indicate sepsis was treated during 
this hospital stay. In this case a query would be made before reporting services.  
 
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 to the enrollee from December 16, 2020, to December 23, 2020.