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 from May 6, 2020, to
May 12, 2020.
You asked the Plan to pay for the inpatient services. You say that the physician's statement that the enrollee has
a particular condition is sufficient. The Plan denied your request. The Plan says the principal diagnosis was not
consistent with the documentation received.
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 A41.51, defined as sepsis due to Escherichia coli
(E. coli). 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 services. Our physician
reviewer found that there was no evidence of a systemic, life-threatening organ dysfunction due to infection,
defining sepsis. Lactic acid and total bilirubin values improved after fluid resuscitation. The enrollee's white
blood count was noted to be elevated, but there was no evidence of a dysregulated host response to infection.
His creatinine and platelet values were within normal limits. The review has determined that the records did not
show that the diagnosis code was supported by the medical records.
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 from May 6, 2020, to May 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD)
procedure you had at an ambulatory surgery center on May 13, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you disagree with this copayment since
this was a preventive service. The Plan denied your request. The Plan says you were charged this copayment
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 a $250
copayment for outpatient surgery.
EGDs are not considered preventive services for which no cost sharing is due. You have been asked to pay a
$250 copayment for the EGD. The EGD 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 the esophagogastroduodenoscopy (EGD) procedure you had at an
ambulatory surgery center on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on April 3, 2021.
You asked the Plan to pay for the initial hospital care. You say that the information submitted does not support
this many services. The Plan denied your request. The Plan says with the information provided it cannot be
determined how the enrollee came to the servicing provider, or whether the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the initial hospital care have not been met. There were no medical records provided for this case.
Therefore, we decided that the Plan does not have to pay for the initial hospital care provided on April 3, 2021.
Appeal type: Home Health
Decision: Partially Favorable

We decided that the Plan has to pre-approve weekly HH SN visits from November 18, 2021, through
December 25, 2021, are supported. We decided that the Plan does not have to pre-approve weekly HH SN
visits from November 9, 2021 through November 17, 2021.
You asked the Plan to pre-approve the services. You say that the enrollee needs catheter care once per week
and a catheter change. You state otherwise the enrollee gets a large buildup of sediment and the catheter clogs
up. The Plan denied your request. The Plan says the enrollee's records indicate that they require a urinary
catheter to help empty the enrollee's bladder. The Plan states the enrollee's catheter changes are scheduled
monthly and their last catheter change was on October 25, 2021. The Plan states the enrollee's next catheter
change should occur on or around November 25, 2021. The Plan states based on a review of the enrollee's
records the previously approved nursing visit(s) should cover the enrollee's scheduled catheter change(s) for the
date(s) requested.
We decided that the Plan has to pre-approve weekly HH SN visits from November 18, 2021, through
December 25, 2021.
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 physician reviewer
found that weekly HH SN visits from November 18, 2021, through December 25, 2021, are supported. There is
evidence to support that weekly HH SN visits were medically necessary during this time period. The enrollee
was experiencing catheter clogging, for which additional care and more frequent catheter changes were
ordered. Therefore, we decided that the Plan has to pre-approve weekly HH SN visits from November 18,
2021, through December 25, 2021.
We also decided that the Plan does not have to pre-approve weekly HH SN visits from November 9, 2021,
through November 17, 2021.
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 physician reviewer
found based on the documentation provided, weekly HH SN visits from November 9, 2021, through November
17, 2021, are not supported. There is no evidence to support why weekly HH SN visits were requested for, or
were medically necessary during, this time period. Therefore, we decided that the Plan does not have to pre-
approve weekly HH SN visits from November 9, 2021, through November 17, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the cone beam computed tomography
(CT) capture and interpretation (D0364 x 2) provided on July 20, 2021.
You asked the Plan to pay the in-network rate for the 2-cone beam CT. You say that the in-network providers
could not see you for months. You say that you went to the dental school to see a specific provider. You say
they were not there. You also say that you feel you were misled. The Plan denied your request. The Plan says
cone beam CT is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay the in-network rate for the
cone beam computed tomography (CT) capture and interpretation (D0364 x 2) provided on July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins (93971) provided on July
21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that the provider requesting this service is a part
of the network and should have requested authorization for these services and you should not be penalized for
them neglecting to do so. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins (93971)
provided on July 21, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing coded 81479 provided on
June 8, 2021.
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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.
We find that CPT code 81479 is not supported in the medical record. Specifically, this claim was not submitted
with the required Z code identifier. Based on this information, we decided that Medicare rules for coverage of
the GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to
pay for the GeneSight Psychotropic testing coded 81479 provided on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided you do
not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the
acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until you are stable to
transfer to a lower level of care such as home with home health 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on May 11, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the OON podiatry services. You say that you had a communication issue with
this provider when you changed plans. The Plan denied your request. The Plan says unauthorized, non-plan
care is not covered.
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 podiatry services provided on May 11, 2021, by an
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the two naturopathy visits provided on June 9, 2021, and July
21, 2021.
You asked the Plan to pay for the naturopathy visits. You say that you would like coverage to be continued for
the naturopathy services because the treatment has proven to be successful. The Plan denied your request. The
Plan says the maximum benefit has been paid for these services.
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only pays
for 6 naturopathy visits/services every calendar year.
We looked at the file and Medicare rules. The record shows that you received naturopathy visits on January 5,
2021, February 2,2021, February 3, 2021, March 2, 2021, March17, 2021, and April 27, 2021, and your
naturopathy benefit has been exhausted. Based on this information, we decided that Medicare rules for
coverage of the naturopathy visits have not been met. Therefore, we decided that the Plan does not have to pay
for the two naturopathy visits provided on June 9, 2021, and July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
July 14, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you believe you should not
be charged for this full mouth x-ray because it was due to the negligence on the part of the provider's office to
verify your benefits to make sure you were eligible for coverage. The Plan denied your request. The Plan says
this service exceeds the benefits offered in your contract.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, full-mouth, periapical or panoramic x-
rays are limited to once every two years. The record shows that you received a complete series of intraoral x-
rays (D0210) on June 23, 2020 and your full-mouth, periapical or panoramic x-rays benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210)
provided on July 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the sleep study (95800) provided on July 9, 2021.
You asked the Plan to pay for the sleep study. You say that you would like this claim to be reconsidered for
payment. The Plan denied your request. The Plan says the polysomnogram (PSG) requires a valid diagnosis
and must meet coverage criteria. The Plan also says that the information provided at the time of the appeal does
not support evidence-based clinical criteria.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 95800 is not supported in the medical record. Specifically, Local Coverage Article
(LCA): Outpatient Sleep Studies (A56923) includes a list of diagnosis codes that support medical necessity.
The LCA also states that any code not listed does not support medical necessity of CPT code 95800. The
diagnosis code on the claim is not listed as a code that supports medical necessity. Based on this information,
we decided that Medicare rules for coverage of the sleep study have not been met. Therefore, we decided that
the Plan does not have to pay for the sleep study (95800) provided on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental
pneumatic appliance (E0673).
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was
prescribed by the doctor and was issued to the enrollee for use during their surgery. You are not contracted
with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied
your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein
thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that
the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance
(E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry visit provided on March 2, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the podiatry visit. You say that you are appealing this claim. The Plan denied
your request. The Plan says no prior authorization was obtained.
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 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 podiatry visit provided on March 2, 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 Group 3 standard power wheelchair (K0861) with accessories.  You asked the Plan to pre-approve a Group 3 standard power wheelchair and accessories. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 Group 3 standard power wheelchair and accessories. Our reviewer says that the requested items exceed the enrollee's medical needs and are not medically necessary. Our physician reviewer found that the enrollee has a mobility deficit that impairs MRADLs. However, the documentation provided does not reveal a detailed neuromuscular exam including strength of the upper and lower extremities. The exam that was performed was via telehealth and it is not clear how angle measurements were made or that a proper neuromuscular and musculoskeletal exam was performed indicating why a manual wheelchair would not work for the enrollee.  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 Group 3 standard power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair (K0861) with accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81408, 81351, and 81479
provided on March 16, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable 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.
We find that CPT codes 81408, 81351, and 81479 are not supported in the medical record. Specifically, when a
laboratory assays two or more genes in an enrollee in parallel. Those two or more genes will be considered part
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel.
Review of the file shows that more than one code was billed for the services rendered. Based on this
information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81408, 81351, and
81479 provided on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 24, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are
not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on April 24, 2021.