Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses identified with codes L1833, L2397, and L2810 
provided on April 19, 2022. 
 
You asked the Plan to pay for the orthoses. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the documentation does not support the need for the items rendered. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the items rendered were not discussed by the enrollee's provider. The 
documentation does not support Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the orthoses identified with codes L1833, 
L2397, and L2810 provided on April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from June 5, 2021, to June 8, 
2021. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the diagnosis billed are not supported by the documentation. 
 
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 A41.9, defined as sepsis unspecified organism. 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 reviewer says that 
the documentation does not support the DRG billed. Our physician reviewer found the enrollee presented with 
chief complaint of dizziness. Hypothermia was documented. c criteria are expected as an appropriate response 
to infection, however, systemic inflammatory response syndrome (SIRS) criteria alone lack specificity as the 
same clinical signs, symptoms and laboratory data seen in patients with sepsis are also present in populations of 
critically ill patients with other proinflammatory conditions. The documentation did not support a manifestation 
of systemic infection beyond that evidenced by SIRS criteria. The enrollee remained hemodynamically stable 
throughout admission with no documentation supporting a dysregulated host response to infection. Though a 
diagnosis of sepsis was noted during the stay, there did not appear to be evidence of significant 
thrombocytopenia, hepatic or acute renal dysfunction, hypoxia, acute mental status changes or persistent 
hypotension. The enrollee remained alert and oriented with Glasgow Coma Scale (GCS) of 15. No 
documentation of mean arterial pressure below 70. Creatinine of 1.49 noted in enrollee with stage 3 chronic 
kidney disease (CKD III) and documentation states this is close to the baseline. History and physical 
documentation stated "The patient was noted to be hemodynamically stable". The principal diagnosis code 
assignment of A41.9, Sepsis unspecified organism is not supported by the 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 the inpatient services provided from June 5, 2021, to June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have acupuncture services acupuncture services you received on January 1, 
2021, under your Wellness Allowance benefit. 
 
You asked the Plan acupuncture services the acupuncture services. You say that you sent in proof of payment. 
The Plan denied your request. The Plan says you did not send in valid proof of payment for the 2021 services, 
which is required for reimbursement under your Wellness Allowance benefit. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. Under your Plan, you are required to submit proof of payment in order to be 
reimbursed under the Wellness Allowance benefit.  Proof of payment would include things like receipts, credit 
card statements, etc.  None of these items were included with your appeal request. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Therefore, we decided that the Plan does not have acupuncture 
services acupuncture services you received on January 1, 2021, under your Wellness Allowance benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics received on April 27, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you would like these items to be reconsidered for 
payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Your contract 
with the Plan covers orthotics one pair per calendar year.  
 
While you meet coverage criteria for the items received, your contract with the Plan covers these items once 
per calendar year. You previously received orthotics on January 18, 2022. This means you had exceeded your 
benefit limit prior to April 27, 2022. Therefore, we decided that the Plan does not have to pay for the foot 
orthotics received on April 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 30, 2021, 
through October 29, 2021. 
 
You asked the Plan to pay for home health services. You say that you could not find a specific reason why the 
claim was denied, and it should be covered. The Plan denied your request. The Plan says a RAP was not billed, 
and it is required to process the final claim. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the RAP was not submitted. Therefore, we 
decided that the Plan does not have to pay for home health services provided from September 30, 2021, 
through October 29, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment for the testing in question because they 
state they reached out to the providers office and confirmed that testing was not ordered. This stands in 
opposition to the signed order form and medical records that were submitted. The Plans submitted evidence 
that testing was not ordered is not supported in this case. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on April 13, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis related group 
(DRG) 871 and secondary diagnosis code N17.0, provided from September 25, 2021, to September 30, 2021. 
 You asked the Plan to pay for inpatient hospital services. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says the services at issue were reported 
with the incorrect DRG. 
 
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 N17.0, defined as Acute 
kidney failure with tubular necrosis. We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 
inpatient hospital services. Our reviewer says that the inpatient hospital services billed with DRG 871 and 
secondary diagnosis code N17.0 do not meet criteria for payment. Our physician reviewer found that the 
review of the available medical records has determined that the records do not support DRG 871 and secondary 
diagnosis N17.0.  
 
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 billed with DRG 871 and secondary diagnosis code N17.0, provided from 
September 25, 2021, to September 30, 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 enrollee clearly exceeds the CMS 
criteria for LTACH admission. The Plan denied your request. The Plan says authorization denied because the 
LTACH is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 
skilled nursing facility (SNF). 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied.  
 
 
 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the Eylea (J0178) and scanning computerized ophthalmic 
diagnostic imaging (92134) provided on January 31, 2022. 
 
You asked the Plan to pre-approve the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that a prior authorization was not obtained for J0178 to render the services 
past the approved units. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found that the 
dosage of Eylea for patients with exudative age-related macular degeneration is 2 mg injected every 4 weeks 
for 5 injections, and then 2 mg every 8 weeks. The dosage of Eylea, 2 mg, is medically reasonable and 
necessary. Optical Coherence Tomography is reasonable and necessary for the evaluation of retinal disease, 
including age-related macular degeneration. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve the Eylea (J0178) and scanning computerized ophthalmic diagnostic imaging (92134) provided on 
January 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery services provided on December 
30, 2021. 
 
You asked the Plan to waive the copayment for the surgery services. You say that you were unaware that there 
was a copayment for the service you received. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was billed. 
 
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 $195 
copayment for all other ambulatory surgical center (ASC) services. The total amount charged was $188.86 
which is less than the copayment amount of $195; therefore, only $188.86 was charged as the copayment 
amount. 
 
  You have been asked to pay a $188.86 copayment for the surgery services. the surgery services fall within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 surgery services 
provided on December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on October 26, 
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 Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
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 the documentation submitted does 
not include a critical care progress note for the billed date of service of 10/26/2021. The review has determined 
that the records do not support that 30-74 minutes of critical care were rendered in this case. 
 
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 critical care services provided to the enrollee on October 26, 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 you are unable to go home and need time at the 
SNF. The Plan denied your request. The Plan says transfer to SNF is not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or 
skilled therapy needs. You are likely at/near a plateau in function, given your weight-bearing restriction and 
leg-length discrepancy. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be 
provided 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 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 waive the copayment for office visit on January 13, 2022, to March 
23, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $35 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). Covered services include consultation, diagnosis, and treatment by a 
specialist. There were two visits. $35 x 2 = $70. Therefore, results in the total cost sharing amount of $70. 
 
 You have been asked to pay a $35 copayment for each office visit. Office visits fall within the 
Physician/Practitioner services, including doctor's office visits 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 office visit on January 13, 2022, to March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 64483. You say that you disagree with the Plan's 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 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 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64483 billed for date of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on October 31, 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 99291 is not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no critical care note 
for the billed date of service. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care 
services rendered on October 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportation provided on 
April 27, 2022, and May 8, 2022. 
 
You asked the Plan to waive the copayments for ambulance services. You say that these services were 
medically necessary, and you were not told you would owe a copayment. The Plan denied your request. The 
Plan says these claims were processed correctly, and your copayments were assessed in accordance with your 
contract. 
 
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 $200 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $200 copayment for each of the two ambulance trips. 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 copayments for the ambulance transportation provided on April 27, 2022, and May 8, 2022.