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

 
We decided that the Plan has to pay for the inpatient hospital services provided from September 29, 2020, to 
October 1, 2020, as billed with DRG 871. 
 
You asked the Plan to pay for inpatient services billed with DRG 871. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says that DRG 
871 is not supported as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record. The Plan argues that DRG 194 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. DRG 871 requires a primary diagnosis of sepsis, organism 
unspecified (A41.9). 
 
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 services billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis (A41.9) is supported in the record. Our physician reviewer found the 
record indicates the enrollee presented with altered mental status. The record indicates that evaluation revealed 
multi-focal pneumonia in a febrile (39.3) enrollee with tachycardia, lactate of 1.4 and low oxygen saturation. 
The record in the emergency room indicated a sepsis risk score of over 15. The record is sufficient to establish 
that the enrollee had sepsis as defined by sepsis 2 criteria. The elements of the coverage criteria are satisfied 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 inpatient services billed with DRG 871 have been met. Therefore, we decided 
that the Plan has to pay for the inpatient hospital services provided from September 29, 2020, to October 1, 
2020, as billed with DRG 871.  
 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 the office visit (99214) and the laboratory service (88305) 
rendered by the out-of-network (OON) provider on August 10, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214) and the laboratory service (88305) rendered by the out-of-
network (OON) provider on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the take home drugs (0253) provided on January 1, 2022. 
 
You asked the Plan to pay for the take home drugs. You say that you did not know this was not a covered 
service. You also say that there was no way to find out if it was covered. The Plan denied your request. The 
Plan says that the take home drugs are considered a Medicare Part D benefit. 
 
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 file does not include an itemized bill. We have requested this 
information and it was not received. Without an itemized bill, it cannot be determined if the take home drugs 
are coverable under your medical coverage. Therefore, we decided that the Plan has to pay for the take home 
drugs (0253) provided on January 1, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Neulasta for the enrollee. 
 
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that that there is no support for the use of this medication in the compendia 
utilized by Medicare or in Medicare approved literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta. Our reviewer says that 
Neulasta is medically reasonable and necessary. Neulasta is FDA-approved for the enrollees diagnosis. The 
patient is receiving intermediate risk chemotherapy (cisplatin/gemcitabine) and age is greater than 65. Use of 
growth factors is recommended by NCCN Guidelines. Neulasta is safe and effective and otherwise reasonable 
and necessary for this enrollee. Our physician reviewer found that the enrollee's condition meets criteria for 
coverage of Neulasta. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
Neulasta for the enrollee.  
 
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 waive the copayment for a diagnostic colonoscopy provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the colonoscopy was 
only a screening, and you believe it was coded wrong. The Plan denied your request. The Plan says medical 
records support a history of colonic polyps, which support a diagnostic colonoscopy. Therefore, the proper 
copayment was applied for a diagnostic colonoscopy. 
 
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 $325 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
  You have been asked to pay a $325 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the Outpatient surgery 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 a diagnostic 
colonoscopy provided on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the operative tissue ablation and reconstruction of atria 
(33259) provided on September 2, 2021. 
 
You asked the Plan to pay for the operative tissue ablation and reconstruction of atria (33259). The Plan denied 
your request. The Plan says procedure code 33430 was approved, and CPT code 33259 remains denied as the 
service is not supported in the medical records submitted. 
 
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 33259 is operative tissue ablation and reconstruction of 
atria, performed at the time of other cardiac procedure(s), extensive (e.g. maze procedure), with 
cardiopulmonary bypass (List separately in addition to code for primary procedure). 
  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 operative tissue ablation and reconstruction of atria 
(33259). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that the operative report does not describe ablation of tissue of the atria then an 
extensive reconstruction of the left and right atrium, or the chambers at the top of the heart. Therefore, CPT 
code 33259 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the operative tissue ablation and reconstruction of atria (33259) have not been 
met. Therefore, we decided that the Plan does not have to pay for the operative tissue ablation and 
reconstruction of atria (33259) provided on September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from October 19, 2021, to October 31, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you were in two different 
facilities for physical and occupational therapy. You say that you did not have acute care. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 per day for days 1-20 and $184 per day for days 21-100 for each benefit period. 
 
 
 SNF Dates Copayment Total 
September 21, 2021  September 30, 2021 (1-9) $0/day $0 
October 1, 2021  October 10, 2021 (10-18) $0/day $0 
October 19, 2021  October 20, 2021 (19-20) $0/day $0 
October 21, 2021  October 31, 2021 (21-30) $184/day $1,840 
Total:  $1,840 
 
The file shows that the enrollee was in the skilled nursing facility three separate times. The enrollee has been 
asked to pay $184 per day for days 21-30 of SNF services, for a total of $1,840. The SNF services fall within 
the Skilled Nursing Facility (SNF) Care benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility (SNF) services provided from October 19, 2021, to October 31, 2021.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the deductible for the nasal endoscopy and specialist office visit. We 
decided that the Plan does not have to waive the copayment for the specialist office visit.  
 
You asked the Plan to waive the deductible and copayment for the nasal endoscopy and specialist office visit. 
You say that the amount you have been charged is incorrect. The Plan says that the amount charged is correct. 
 
We decided that the Plan has to waive the deductible for the nasal endoscopy.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that surgery services received at a primary care physician's office or a specialist's 
office do not apply to your combined annual deductible. This means that the deductible applied incorrectly. 
Therefore, we decided that the Plan has to waive the deductible and copayment for the nasal endoscopy.  
 
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 $20 
copayment for a specialist office visit. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist office visit. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram screening provided on December 29, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mammogram screening. You say that the service rendered to the enrollee was 
a yearly screening. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 mammogram screening provided on December 
29, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the robotic upper extremity orthosis. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the robotic upper extremity orthosis. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. 
 
 
 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 robotic upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a robotic upper extremity orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the two dental bone replacement grafts (code D7953) 
and guided tissue regeneration services (code D4266) you requested. 
 
You asked the Plan to pre-approve the two dental bone replacement grafts and guided tissue regeneration 
services. You say that you do not understand why these services were denied.  You said that you need these 
services to close the hole from the dental extraction you had. The Plan denied your request. The Plan says these 
dental services are not covered for any reason. 
 
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.  Only the dental services listed in Schedule A of your Description of 
Benefits and Copayments document are eligible for coverage. The two dental bone replacement grafts and 
guided tissue regeneration services are not listed as covered services under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve the two dental bone replacement grafts (code D7953) and guided 
tissue regeneration services (code D4266) you requested.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from 
November 9, 2021, to November 16, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you were discharged 
on November 5, 2021, without a proper diagnosis or treatment plan, and were readmitted to the same hospital a 
few days later for the exact same issue after passing out at home. You also say that you believe the three days 
copayment associated with the with this claim should be credited towards the copayment for the previous 
hospital stay since these two hospital stays were within a couple of days of each other, and for the exact same 
medical condition. The Plan denied your request. The Plan says you were charged the correct cost sharing 
amount.  
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 $325 
copayment per day for days 1 to 5 for inpatient hospital care. Your contract with the Plan also clearly says that 
your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility 
type, including inpatient rehabilitation facilities, long term acute care (LTAC) facilities, and inpatient 
psychiatric facilities.  
 
You have been asked to pay a $325 copayment per day for 5 days of inpatient hospital services, which totals 
$1,625 ($325 x 5 = $1,625). Inpatient hospital services fall within the inpatient hospital care 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 inpatient hospital services rendered from November 9, 2021, 
to November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DermTech Pigmented Lesion Assay (PLA) rendered on 
September 13, 2021. 
 
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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that PLA testing is covered 
when specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of neoplasm 
of uncertain behavior of skin on the nasal tip, which exhibits color variation. The differential diagnosis 
included malignant melanoma in situ versus dysplastic nevus. The enrollee has a history of malignant 
melanoma at the site. The documentation does not support that the enrollee had a primary melanocytic skin 
lesion between 5mm and 19mm in an area that did not contain a scar or was previously biopsied. The 
documentation is insufficient to demonstrate that it was reasonable and medically necessary for the enrollee in 
this case to have the DermTech PLA. 
 
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 pay for the DermTech Pigmented Lesion Assay (PLA) rendered on September 13, 2021.