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

 
We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related 
group (DRG) code 689. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 689. You say that the 
documentation in the medical record clearly supports the clinical diagnosis of G93.41 metabolic 
encephalopathy. The Plan denied your request. The Plan says DRG 689 is not supported as the diagnosis of 
metabolic encephalopathy. 
 
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 secondary diagnosis code, G93.41, defined as 
Metabolic encephalopathy. 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 billed with DRG 689. Our reviewer says that DRG 689 was not supported as the diagnosis of 
metabolic encephalopathy. Our physician reviewer found he reviewed documentation was inconsistent/unclear 
regarding a diagnosis of metabolic encephalopathy. Our reviewer found that even though metabolic 
encephalopathy was documented on progress notes and discharge summary, supporting medical record 
documentation was not found within the record. Our physician reviewer also found that while member 
presentation warranted consideration of Metabolic encephalopathy there was no documentation to support a 
change in mental status beyond baseline that persisted beyond treatment in the emergency department and no 
documentation of neurological exams consistent with a diagnosis of encephalopathy or diagnostic work ups 
were done.  
 
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 the inpatient hospital services billed with diagnosis related group (DRG) code 689.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the renflexis injection provided by
the Hospital on October 12, 2020.
You asked the Plan to waive the copayment for the renflexis injection. You say that the infusion gave you an
allergic reaction, so you are disputing the cost. The Plan denied your request. The Plan says the claim
reprocessed to only apply a $50 copayment.
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 $50
copayment for Part B drugs that are administered by an in-network provider.
You have been asked to pay a $50 copayment for the renflexis injection. The renflexis injection falls within the
"Medicare Part B prescription drugs" 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 renflexis injection provided by the Hospital on October 12, 2020.
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 short-term rehabilitation is medically necessary, 
reasonable, and appropriate for the enrollee. The Plan denied your request. The Plan says the denial of 
authorization for SNF care is correct. 
 
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 the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on May 12, 2021. 
  You asked the Plan to pay for the occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as 
services incident to a physician/non-physician practitioner's service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided 
by an occupational therapist on May 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the required drug, zoledronic acid. 
  
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has tried and failed the required drug, zoledronic acid. The reviewer found that there is no 
documentation indicating that the Plan?s required drug would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the reviewer found that the step therapy criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Specifically, the file shows that the enrollee has not 
tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia 
(J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography studies represented by code 
51785 provided on April 9, 2021. 
 
You asked the Plan to pay for code 51785. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that code 51785 was billed with diagnosis code 
M51.36. This diagnosis code is not a covered diagnosis code for code 51785. Therefore, we decided that the 
Plan does not have to pay for the needle electromyography studies represented by code 51785 provided on 
April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatrist office visit (99213) provided on 
February 11, 2021. 
 
You asked the Plan to waive the copayment for a podiatrist office visit. You say that you do not believe this 
office visit took place. The Plan denied your request. The Plan says this processed 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 $5 
copayment for specialist office or telehealth visits.  
 
You have been asked to pay a $5 copayment for a podiatrist office visit. 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 podiatrist office visit (99213) provided on February 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have 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 you are a 58-year-old male with falls, 
astrocytoma, seizures and chronic obstructive pulmonary disease. While there are identifiable skilled therapy 
service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled 
nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from February 
5, 2021, to March 7, 2021. 
 
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 Medicare no longer pays for a Request for Anticipated Payments (RAP) on services done. 
 
The Plan must follow Medicare rules. The rules say that all home health agencies (HHAs) must submit a 
Request for Anticipated Payments (RAP) within five calendar days after the start of care and within five 
calendar days after the "from date" for each subsequent 30-day period of care. 
  
The file shows that the RAP claim was submitted on May 7, 2021, which is more than five days after the "from 
date" of February 5, 2021. 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 home health services 
provided to the enrollee from February 5, 2021, to March 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an implant removal 
(D6100) provided on June 10, 2021, to June 29, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and an implant removal. You say that you are 
requesting reconsideration to have the denied services covered and processed for payment. The Plan denied 
your request. The Plan says there is no coverage for a limited oral evaluation or an implant removal. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) and an implant removal (D6100) provided on June 10, 2021, to June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
19, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you visited multiple providers in 
2020 due to your old provider retiring and Covid-19. The Plan denied your request. The Plan says you have 
used this benefit. 
 
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. The Plan covers a 
comprehensive oral evaluation once every three years.  
 
 
 We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation 
on September 4, 2020, therefore, you have exhausted your maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been 
met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2), unspecified periodontal 
service (D4999 x 2), and take-home medication (D9630) provided on June 1, 2021. 
 
You asked the Plan to pay for the gingival irrigation, unspecified periodontal service, and take-home 
medication. You say that you were advised that the service would have been covered if you had waited a little 
longer. You say that you had a broken tooth and needed a crown.  
 You also say that you needed these services in order to get the crown. The Plan denied your request. The Plan 
says the gingival irrigation, unspecified periodontal service, and take-home medication are not listed as covered 
dental services. 
 
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 gingival irrigation, unspecified 
periodontal service, and take-home medication are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2), unspecified periodontal 
service (D4999 x 2), and take-home medication (D9630) provided on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy injections you received on 
March 7, 2019, and March 28, 2019. 
 
You asked the Plan to waive the coinsurance for the chemotherapy injections. You say that no one has 
explained what these charges are for, and now you are being sent to collections. The Plan denied your request. 
The Plan says you were charged this coinsurance correctly.  The Plan says that you had not met your out-of-
pocket maximum at the time of these services. 
 
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 15% 
coinsurance for Medicare Part B drugs.  
 You have been asked to pay 15% coinsurance for the chemotherapy injections. The chemotherapy injections 
fall within the Medicare Part B drugs 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 coinsurance for 
chemotherapy injections you received on March 7, 2019, and March 28, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services beginning on 
November 1, 2021. 
 
You asked the Plan to pre-approve SNF services. You say that you require SNF care. The Plan denied your 
request. The Plan says rules for SNF care have 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that based on the documentation 
provided, you do not have documented skilled nursing needs. You do not have documented skilled therapy 
needs. You are consistently ambulating more than 100 feet and tending to activities of daily living with 
minimal supervision. Daily skilled services are not shown to be required to establish a maintenance program or 
to prevent deterioration of your 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services beginning on November 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
July 1, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you stopped at the hospital to ask a 
question about headaches, and you say you were not allowed to speak to anyone unless you provided your 
information. You stated that you did not want to stay for services, but you were talked into it. 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 $90 
copayment for emergency room visits.  
 
 You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason 
for the ER visit. 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 emergency room (ER) visit 
you had on July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be gradually improving but is still not stable enough for 
transfer. There are no services at the LTACH that the enrollee requires that are not already available and 
covered 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code 
70450 provided on June 28, 2020. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan represented by code 70450 provided on June 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection rendered on May 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 procedure code 96374 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 96374 (diagnostic. therapeutic, or prophylactic injection) 
and 78451 (myocardial perfusion imaging). Code 96374 is a column II code with a modifier indicator of 1 
when billed with column I code 78451. Code 96374 was not billed with an appropriate modifier to allow for 
separate payment. Therefore, we decided that the Plan does not have to pay for the injection rendered on May 
13, 2021.