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 to the enrollee from 
October 13, 2021, to October 20, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says principal code A41.9 and secondary code 
R65.20 were removed from the claim. 
 
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 DRG 872. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that one SOFA point for altered mental status was initially present but this resolved and left even less evidence 
of sepsis being present. Sepsis 3 criteria was not met and there was insufficient evidence of a systemic 
dysregulation response to the infection. The records do not sufficiently support the use of diagnosis code A41.9 
(Sepsis, unspecified organism) or diagnosis code R65.20 (Severe sepsis without septic shock) in this case. 
Therefore, the records also do not support DRG 872 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV 
>96 HOURS WITHOUT MCC). DRG 603 (CELLULITIS WITHOUT MCC) is a more appropriate code for 
this admission based on the provided documentation.   
 
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 October 13, 2021, to October 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 76705 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 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 procedure code 76705 billed for date of service August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #9 (D2740), core build up on tooth #9 
(D2950), and alveoloplasty in the lower left and right quadrants (D7310). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial for dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a crown and core build up on tooth #9 was exhausted on date of service May 17, 2022. 
The record also shows your benefit for alveoloplasty in the lower left and right quadrants was exhausted on 
date of service June 30, 2022. Therefore, we decided that the Plan does not have to pre-approve a crown on 
tooth #9 (D2740), core build up on tooth #9 (D2950), and alveoloplasty in the lower left and right quadrants 
(D7310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device you billed for date of service June 2, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this item was billed with an accepted procedure 
code. The Plan denied your request. The Plan says you did not provide adequate proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, the delivery documentation you provided 
does not provide an itemized listing of the items delivered to the patient. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device you billed for date of 
service June 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 5, 2022, to 
April 3, 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 March 5, 2022. The NOA was not received by the Plan until June 8, 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 
March 5, 2022, to April 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
without contrast material (72148). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee has low back pain, 
with an unknown duration. The enrollees neurological exam was normal. The intake note indicates that he had 
a physical evaluation on May 18, 2022 but no physical therapy program that ensued. Absent a documentation 
of conservative management with post program evaluation, the medical necessity of the requested MRI has not 
been established in the submitted records particularly with no red flags identified. Of interest is the documented 
presence of an implanted pacemaker and defibrillating device. Depending on the manufacturer and type of 
implanted device this often represents an absolute contraindication to an MRI. Contact with the device 
manufacturer would ultimately be necessary to determine if an MRI could eventually be approved after 
appropriate conservative management, if an MRI could be safely accomplished. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine without contrast material (72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided 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 already 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued treatment with tumor treatment field therapy 
(TTFT) on July 15, 2021. 
 
You asked the Plan to pay for the treatment. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for treatment of recurrent glioblastoma. 
 
The Plan must follow Medicare rules. Medicare rules say that TTFT for recurrent glioblastoma is not covered.  
 
The enrollee's diagnosis of glioblastoma is recurrent as it was diagnosed in 2017. Based on this information, we 
decided that Medicare rules for coverage of the treatment have not been met. Therefore, we decided that the 
Plan does not have to pay for continued treatment with tumor treatment field therapy (TTFT) on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing (0012M) provided on June 21, 
2022. 
 
You asked the Plan to pay for the CxBladder Detect testing. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CxBladder Detect testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the CxBladder Detect testing (0012M) provided on June 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of adequate design trials using this modality in the treatment of chronic 
knee pain due to osteoarthritis. 
 
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 blocks. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the role of genicular nerve blocks and radiofrequency ablation is the subject of ongoing clinical 
trials. It is still considered experimental and investigational. 
 
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 blocks have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genicular nerve blocks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollees condition they do not meet all the requirements. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Stelara. Our reviewer says that the 
requirements for coverage of Stelara have not been met. Our physician reviewer found the Plan requires a trial 
of Entyvio before they will approve the requested drug. There is no evidence that you have tried and not 
responded to Entyvio or that Entyvio would likely be less effective or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stelara.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pimecrolimus. 
 
You asked the Plan to pre-approve Pimecrolimus. You say that the services are necessary. 
 The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
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 Pimecrolimus.  
 
Benefits for Pimecrolimus 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic 
appliance for use with pneumatic compressor to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance for use with 
pneumatic compressor to be provided by an OON provider. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in-network providers that are able to provide these services. 
Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and segmental pneumatic appliance for use with pneumatic compressor to be provided 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic hearing exam provided on 
August 1, 2022. 
 
You asked the Plan to waive the copayment for diagnostic hearing exam. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $40 
copayment for hearing services.  
 
You have been asked to pay $40 copayment for diagnostic hearing exam. This item/service falls within the 
hearing services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for diagnostic hearing 
exam provided on August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services provided on May 25, 
2022. 
 
You asked the Plan to pay for the CxBladder genetic testing services. You say that you would like this claim 
reprocessed and approved for payment for medical necessity. The Plan denied your request. The Plan says this 
testing is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy that was 
reaffirmed for current procedural terminology (CPT) codes 0012M and 0013M for CxBladder genetic testing 
services. Based on this information, we decided that Medicare rules for coverage of the CxBladder genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder 
genetic testing services provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Monitor testing (0013M) provided on May 24, 
2022. 
 
You asked the Plan to pay for the Cxbladder Monitor testing. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Monitor testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Monitor testing (0013M) provided on May 24, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided medical records document 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. The home ventilator is being 
requested for use in average volume assured pressure support (AVAPS) mode with auto-titration (AE) which 
could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate.  As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not reasonable and 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 3, 2022 to June 1, 
2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 admit date on the claim does not match the "from" date on the NOA (January 3, 2022). 
Therefore, we decided that the Plan does not have to pay for home health services provided on May 3, 2022 to 
June 1, 2022.