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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 23, 2021, 
to December 25, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
reported diagnoses are supported by the records, and the original DRG should be paid. The Plan denied your 
request. The Plan says the DRG was changed as the reported diagnoses on the claim were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis code E87.2, defined as acidosis. 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 two diagnosis codes at issue in this case are not supported by the records. Our physician 
reviewer found sepsis is a life-threatening syndrome usually caused by bacterial infection. Sepsis is a response 
of the body's immune system that results in organ dysfunction or failure. In this case, there was no clinical or 
laboratory evidence of sepsis. The review has determined that the documentation did not support principal 
diagnosis code A41.9, defined as sepsis, unspecified organism. 
 
Metabolic acidosis is a clinical disturbance characterized by an increase in plasma acidity. Metabolic acidosis 
should be considered a sign of an underlying disease process. The diagnosis of acidosis requires either a lactic 
acid greater than 4mmol/L, which requirement is specific to the diagnosis of lactic acidosis, an arterial pH less 
than 7.35 with a bicarbonate less than 22mEq/L or a pCO2 greater than 45mmHg, or a venous pH less than 
7.32 with a bicarbonate less than 25mEq/L. Those conditions were not met. The documentation did not support 
secondary diagnosis code E87.2, defined as acidosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 23, 2021, to December 25, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on April 30, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the transportation via ambulance from the hospital to a 
nursing home was not medically necessary.  Our physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided 
by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on April 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO), sagittal-coronal control, with 
rigid anterior and posterior frame/panel provided to the enrollee on September 7, 2022. 
 
You asked the Plan to pay for the services. You say that the reason that the patient needed the back brace is 
documented in the chart notes from the face-to-face exam. The Plan denied your request. The Plan says the 
services were not furnished directly to the patient and/or not documented. 
 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 that there is no documented lumbar fracture or instability. Lumbar bracing for degenerative back pain is 
experimental. 
 
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 a lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior 
frame/panel provided to the enrollee on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis and orthosis additions to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a knee orthosis and orthosis additions. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested items can be provided by a network 
provider. 
 
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 knee orthosis and orthosis additions 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 pay for a pacemaker insertion (33274) provided on August 19, 2022. 
 
You asked the Plan to pay for the pacemaker insertion. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code cannot be paid as billed. 
 
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 33274 is Transcatheter insertion or replacement of 
permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous 
ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming). 
 
We find that CPT code 33274 is not supported in the medical record. Specifically, the service was billed 
without the required Q0 modifier to denote an investigational procedure. Based on this information, we decided 
that Medicare rules for coverage of the pacemaker insertion have not been met. Therefore, we decided that the 
Plan does not have to pay for a pacemaker insertion (33274) provided on August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of morphometric analysis, in situ 
hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each 
multiplex probe stain procedure provided to the enrollee on April 4, 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 MUE allows for 5 units. 
 
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 88374 is "Morphometric analysis, in situ hybridization 
(quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe 
stain 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that based on the MUE tables for the 
services in question, 5 units are allowed. The records show possibly six units, but it cannot be confirmed that 
all six units were billed, as the case file does not contain the claims. Five units were billed and paid. 
 
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 additional units of morphometric analysis, in situ hybridization (quantitative or semi-
quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure 
provided to the enrollee on April 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 15, 2022 to 
September 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 15, 2022 to 
September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
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 that the enrollee is medically stable and does not need a physical medicine and rehabilitation physician's supervision three times a week in an IRF. There are no acute rehabilitation nursing 
needs identified or documented. At the current functional level, 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 in an 
IRF. The documentation does not support necessity for admission to an IRF due to lack of medical or 
rehabilitation complexity. While the enrollee may benefit from physical therapy and occupational therapy, the 
enrollee's rehabilitation needs can be provided in a lower intensity and alternate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Artacent Wound (skin substitute treatment for the 
wound of the right ear) and the application of the wound treatment (code Q4169 & 15275). 
 
You asked the Plan to pre-approve Artacent Wound and the application of the wound treatment. You say that 
Artacent Wound and the application of the wound treatment is medically necessary. The Plan denied your 
request. The Plan says Artacent Wound and the application of the wound treatment 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 pre-approve Artacent Wound and the application 
of the wound treatment. Our reviewer says that the requested Artacent Wound and the application of the 
wound treatment is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 79-year-old with squamous cell carcinoma of right ear with a request for Artacent 
Wound treatment. The documentation indicates that the enrollee is status post removal of right superior 
parietal scalp lesion and excision of tumor located on the right superior curs of antihelix of the ear. Final defect 
size is 1.6 x 1.6 cm. The review has determined that the requested items are not indicated as standard of care for the treatment of the enrollee's condition. The review has determined that Artacent Wound and the 
application of the wound treatment services at issue in this case are not medically reasonable or 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 Artacent Wound and the application of the wound treatment have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Artacent Wound (skin substitute 
treatment for the wound of the right ear) and the application of the wound treatment (code Q4169 & 15275).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a detachable scooter. 
 
You asked the Plan to pre-approve a scooter. You say that you are trying to get a detachable scooter because 
the one you have is too big and you cannot use it anywhere. You were advised to pick a make and model and to 
give it to your primary physician, which you did, and they still refuse to fulfill the order. The Plan denied your 
request. The Plan says the Medicare criteria has not been met. Medicare does not provide a power wheelchair 
for outdoor use. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a 4-wheel power scooter. You obtained your current scooter February 23, 2021. 
The records also show that the requested scooter is for use outside of the home. Medicare does not provide a 
power wheelchair for outdoor use. The 4-wheel power scooter serves the same purpose as the detachable 
scooter. Therefore, we decided that the Plan does not have to pre-approve a detachable scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377, K0108). 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says this request exceeds the enrollee's needs. 
 
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 additional accessories. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided records document that the enrollee has 3/5 right upper extremity 
grasp strength and there is lack of documentation that he does not possess adequate upper extremity strength to 
operate the wheelchair's power options with their own switches. The requested backpack holder is statutorily 
non-covered as it serves no primary medical purpose. 
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy, with insertion of permanent 
adjustable trans-prostatic implant. 
 
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 requested services are not covered and are excluded for payment purposes. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that cystourethroscopy, with insertion of permanent adjustable trans-prostatic implant is not medically 
reasonable and necessary in this case. Urolift is considered experimental or investigational in men with urinary 
retention. A clinical trial (PULSAR) is now enrolling patients to evaluate this indication. 
 
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 cystourethroscopy, with insertion of permanent adjustable trans-prostatic implant.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 77067 and procedure code 
77063 billed for date of service September 1, 2022. 
 
You asked the Plan to pay for procedure codes 77067 and 77063. You say that you feel that this claim should 
be paid. The Plan denied your request. The Plan says the number of units billed of 77067 exceeds the 
maximum allowed. As such, code 77063 can also not be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77067 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Since code 77067 was denied, and code 77063 is an add-on code, 77063 also cannot 
be paid. Based on this information, we decided that Medicare rules for coverage of procedure codes 77067 and 
77063 have not been met. Therefore, we decided that the Plan does not have to pay for two units of procedure 
code 77067 and procedure code 77063 billed for date of service September 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 13, 2022, to 
February 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should not be denied 
because you did submit an NOA for this period of care. The Plan denied your request. The Plan says the claim 
has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 13, 2022, to 
February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0481) provided to the 
enrollee on January 10, 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 there was no referring provider records submitted. 
 
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 that based on the medical records provided there is no documentation that the records sufficiently show a 
need for this testing. The provided medical records do not include any treating provider records documenting 
the need for definitive drug testing services.  
 
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 drug testing services (procedure code G0481) provided to the enrollee on January 10, 2022.