Persius/hicric huggingface dataset:
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 you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says based on Medicare guidelines, the long term acute 
care hospital services you are requesting do not meet the requirements for approval. 
 
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 was admitted to the acute care hospital with cerebrovascular accident, 
complicated by atrial fibrillation, aspiration pneumonia, and acute chronic respiratory failure requiring a 
craniotomy, antibiotics, and mechanical ventilation support. Trach and percutaneous endoscopic gastrostomy 
were placed. Recent notes describe the enrollee with resolved infections, tolerating pressure support trials and 
occasionally following commands but with persistent significant neurological deficits.  
 
 The enrollee appears to be more stable and tolerating weaning over the past two weeks and should only require 
short-term additional acute care services that can safely be administered at the current facility until more stable 
and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
available at the current facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (procedure code G0481) provided to 
the enrollee on March 7, 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 records do not support that a definitive drug test was performed. 
 
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 G0481 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed." 
 
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 the documentation does not 
support a definitive drug test was performed, as the documentation states all results are presumptive only 
because urine drug screen is not with cross reactive and requires confirmation for definitive results. 
 
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 definitive drug testing (procedure code G0481) provided to the enrollee on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod disposable insulin infusion pump. 
 
You asked the Plan to pre-approve Omnipod. You say that you are appealing this denial. The Plan denied your 
request. The Plan says disposable drug delivery systems are not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery devices are not covered 
by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Omnipod have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
Omnipod disposable insulin infusion pump.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from September 27, 
2021, to September 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were never in the hospital. The Plan 
denied your request. The Plan says Medicare does not pay for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
The drugs provided during outpatient hospital care, that you would normally self-administer are not among the 
types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the 
self-administered drugs provided from September 27, 2021, to September 28, 2021.  Benefits for the services provided 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 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 procedure code 76700 billed for date of service April 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture services provided on December 20, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that the services should be covered. The Plan 
denied your request. The Plan says that the services do not meet the criteria for coverage. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan has not substantiated their denial. Therefore, we decided 
that the Plan has to pay for the acupuncture services provided on December 20, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81479) provided on September 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. The Plan denied 
your request. The Plan says the services were not authorized 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 services (81479) provided on September 
16, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on June 1, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for x-ray. You say that you are appealing the claim payment denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 x-ray provided on June 1, 2022, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Gelsyn-3 injections (J7328) and administration 
(20610) provided from May 11, 2022, to May 26, 2022. 
 
You asked the Plan to reimburse you for the physician services. You say that these injections have worked the 
best for relief of your pain and mobility. You say that you have had to pay out of pocket for these services. You 
also say that you should be reimbursed for these medically necessary services. The Plan denied your request. 
The Plan says prior authorization was not obtained before the services were rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the Gelsyn-3 injections (J7328) and administration (20610) provided from May 11, 2022, to 
May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, a radiologic examination, spine, 
cervical, manual therapy techniques and electrical stimulation provided from April 11, 2022, to May 17, 2022. 
 
You asked the Plan to pay for a new patient office visit, a radiologic examination, spine, cervical, manual 
therapy techniques and electrical stimulation. The Plan denied your request. The Plan says coverage of 
chiropractic service is specifically limited to treatment by means of manual manipulation of the spine to correct 
a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a new patient office visit, a radiologic examination, spine, cervical, manual 
therapy techniques and electrical stimulation provided from April 11, 2022, to May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee needs this. The Plan denied your 
request. The Plan says the repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three months. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee experienced at least 50% pain relief for at least 3 months. The reviewer 
found that there is no documentation of technical issues necessitating a repeat injection. Therefore, the reviewer 
found that the repeat ESI is 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and 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 an office visit provided on April 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 27, 2021, to July 
30, 2021, as billed with Diagnosis Related Group (DRG) 163. 
 
You asked the Plan to pay for inpatient care billed with DRG 163. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 163 is not appropriate as the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the medical 
record. The Plan argues that DRG 164 is more appropriate in this case. 
 
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 inpatient care billed with DRG 163. Our 
reviewer says that the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the 
medical record for this inpatient admission. Our physician reviewer found that the enrollee was admitted to the 
hospital and treated for a pulmonary embolism. He was hypoxic in the emergency department and was given 
4L/m oxygen support. Following initial treatment which consisted of bronchodilators, the enrollee was back on 
room air with 96% oxygen saturation and other vitals stable without respiratory distress; however, oxygen was 
continued later when the enrollee went down to down to 88% on room air. Still, the enrollee did not require 
oxygen supplementation rates at 5 L/m or higher and did not require bilevel positive airway pressure (BiPAP) 
or vent support to meet the criteria for acute respiratory failure with hypoxia. Therefore, the medical records do 
not sufficiently support the billing of acute respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 163 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 27, 2021, to July 30, 2021, as 
billed with Diagnosis Related Group (DRG) 163.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75820 billed for date of service September 
20, 2021. 
 
You asked the Plan to pay for procedure code 75820. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 75820 is bundled into payment for code 37238.  
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 75820 
is a column II code to column I code 37238. 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 75820 billed for date of service September 20, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not indicate that the results of the low dose computed 
tomography (LDCT) or other testing is strongly suspicious of malignancy. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the services. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the patient had a 
CT scan 7/27/22 with pulmonary nodules too small to be characterized on PET and axillary lymph nodes felt to 
be reactive and ultrasound was recommended. If there are ongoing symptoms a CT scan could be repeated as 
nearly 3 months from prior scan. A PET scan is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 13, 2020, to May 31, 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 there is no physician documentation showing a diagnosis of malnutrition, or a risk for 
malnutrition. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
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 the New England Community 
Medical Services Progress Note dated 5/14/2020 does not document malnutrition or risk for malnutrition. The 
Admission/Annual HANDP note dated 5/15/2020 does not document malnutrition or risk for malnutrition. The 
Progress Note dated 5/18/2020 does not document malnutrition or risk for malnutrition. The 
Swallowing/Nutritional Status on 5/19/202 does not document malnutrition or risk for malnutrition. The 
available clinical documentation in the case file does not support that the enrollee had an active diagnosis of 
malnutrition, or was at risk for malnutrition. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from May 13, 2020, to May 31, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 26, 2022.