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

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 14, 2021, to January 18, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there was no new documentation or clinical 
evidence presented to support an overturn of the initial audit findings. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 351. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that there were no signs or symptoms suggesting acute renal failure in the provided documentation. Therefore, 
the documentation provided does not sufficiently support the diagnosis of acute renal failure and the DRG of 
352 would be most appropriate for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from January 14, 2021, to January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no history of pulmonary disease submitted. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee suffered a cerebrovascular accident in November 2022. There is no diagnosis of lung disease, such as 
chronic obstructive pulmonary disease (COPD), or diagnosis of thoracic restrictive disease or generalized 
neuromuscular disease. Overnight oximetry showed desaturations consistent with obstructive sleep apnea 
(OSA). There is no arterial blood gas documenting C02 retention. The enrollee may benefit from a sleep study and continuous positive airway pressure (CPAP) if OSA is confirmed. However, the patient does not have a 
diagnosis or condition that warrants nocturnal ventilation. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
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 services are necessary to for the 
enrollee to regain maximum function. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer at this time. 
 
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 documentation does not support that the member has need for complex medical 
treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly 
medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent 
intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound 
care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like cardiac 
monitors, on-site dialysis, or surgical suites).  The member does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility.  The requested treatments are not medically necessary at the LTACH level of care.  The member continues to require care at an acute inpatient hospital.  He 
can receive further care at the current acute care hospital or a lower level of care when deemed appropriate.   
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 8, 2022, to April 11, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the determination to remove diagnosis code 
R65.21 was upheld. 
 
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 diagnosis code R65.21. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that in this case, there was no clinical or laboratory evidence of sepsis. The review has 
determined that  the documentation did not support diagnosis code R65.21 - severe sepsis with septic shock.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 8, 2022, to April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 58661 billed for date of service October 29, 
2021. 
 
You asked the Plan to pay for procedure code 58661. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 58661 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line of this code with modifier LT and one with 
modifier RT.  Instead, you should have billed a single line item with the 50 modifier to indicate that the 
procedure was performed bilaterally. Based on this information, we decided that Medicare rules for coverage of 
procedure code 58661 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 58661 billed for date of service October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on May 4, 
2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there are no medical records on file to support the medical necessity for the services 
requested. 
 
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 the patient metastatic high-grade serous carcinoma of Mullerian origin (ovarian cancer) based on a 
pathology report. However, based on this information, the patient is in the 12th percentile for tumor mutational 
burden with microsatellite instability status stable. Additional information was not provided such as clinical 
documentation to describe why a large panel vs focused gene SNP testing was ordered or how it would 
specifically lead to a change in treatment and overall outcome for this patient as required by the criteria. 
Therefore, based on the provided documentation, the patient does not meet criteria, and there was insufficient 
clinical rationale presented for the Tempus xT Solid Tumor & Heme CGP Panel at this time. 
 
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 genetic testing services provided to the enrollee on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services (D1110, D0274, D5211, D0120) 
provided on August 17, 2022 to September 21, 2022 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your $2,000 dental benefit maximum 
allowance for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 21, 2022. 
Therefore, we decided that the Plan does not have to pay more for the dental services (D1110, D0274, D5211, 
D0120) provided on August 17, 2022 to September 21, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple procedures on the right leg arteries. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that the enrollee cannot perform activities of daily living, has tried 
cilostazol, structured exercise, or been offered a surgical alternative. 
 
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 the documentation does not support the medical necessity of the treatments in question. The patient 
is a 78-year-old man with a history of hip replacement and degenerative disc disease who reports pain with 
prolonged walking. It is not documented that the patient finds these symptoms to be lifestyle 
limiting. Additionally, it is documented that he has palpable pulses and near-normal ankle brachial 
index. There is no evidence of limb threat documented. 
 
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 multiple procedures on the right leg arteries.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
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 treatment is not indicated or support for this type of cancer. 
 
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 the records on this patient are very limited and while the case records describe a solitary 
oligometastasis the records also state that all other areas have improved which is suggestive of widespread 
disease with an area of residual disease though it is unclear of this lesion is growing or why radiation was 
recommended. The case files does not provide any basis from published evidence, consensus guidelines or 
other source that would support medical necessity. 
 
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 stereotactic body radiation therapy (SBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-
rays (D0220, D0230) provided on June 30, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the comprehensive oral evaluation 
has already been exhausted and coverage for the intraoral x-rays denied correctly as they do not fall under your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 21, 2022 
(D0150). Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) and intraoral x-rays (D0220, D0230) provided on June 30, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vascular surgery and anesthesia (procedure codes 31623, 
31625, 31629, 99152) provided to the enrollee on February 28, 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 records do not support the services 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 the denied codes is: 
 
CPT 31623: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected 
brushings 
 
CPT 31625: 
 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or 
endobronchial biopsy(s), single or multiple sites 
 
CPT 31629: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle 
aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
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 Our 
reviewer found that there is inadequate documentation for the procedure codes in question. The patient 
apparently underwent bronchoscopy with needle aspiration biopsy on 2/28/22, with moderate sedation, but the 
records do not include a detailed procedure note documenting what procedures were performed, medications 
administered, the findings, and outcome/complications. The only documentation provided are hospital progress 
notes prior to the procedure and a fine needle apsiration (FNA) cytology report. 
 
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 vascular surgery and anesthesia (procedure codes 31623, 31625, 31629, 99152) provided to the 
enrollee on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature with 
ankle feature and other parts. 
 
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 request for a K3 foot is not reasonable or 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not demonstrate a need for these items. The enrollee is not a K3-level 
ambulator at this time. The evaluation noted anticipated functional level with a prosthesis is K3. Moreover, 
there is no indication that he has trialed a previous prosthesis, and therefore an advanced prosthetic is not 
indicated. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 a prosthetic leg with an advanced foot feature with ankle feature and other parts.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 are functioning at a home care level for rehabilitation. Daily skilled care is not 
medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Syn-ONE skin biopsy test (88305, 88314, 88346). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is not enough published evidence to support the validity and 
effectiveness of the test requested by the enrollee's doctor. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that the items/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 the services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Syn-ONE skin biopsy test (88305, 88314, 88346).