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

 
We decided that the Plan does not have to pay for inpatient care provided from December 12, 2020, to 
December 15, 2020. 
 
You asked the Plan to pay for inpatient care. You say that this stay was authorized. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not count the day of discharge or 
death for cost report, utilization or Pricer purposes unless the admission and discharge day are the same day. 
 
We looked at the file and Medicare rules. The record shows that four days of inpatient care were billed; 
however, the date of discharge should not be counted, so three days should have been billed. Based on this 
information, we decided that Medicare rules for coverage of inpatient care have not been met.  
 
  
 
Therefore, we decided that the Plan does not have to pay for inpatient care provided from December 12, 2020, 
to December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus Gene panel (81162, 81191, 81206, 81275, 81276, 
81292, 81295, 81298, 81301, 81317, 81404) provided on May 10, 2021. 
 
You asked the Plan to pay for a Tempus Gene panel. You say that this is a covered service. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX, and it is a test 
not currently satisfactorily described by any existing code. Therefore, to report a CGP service, test providers 
should use code 81479 at this time.  
 
We find that CPT codes 81162, 81191, 81206, 81275, 81276, 81292, 81295, 81298, 81301, 81317, and 81404 
are not supported in the medical record. Specifically, these codes were used to report a CGP service, which 
should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of a 
Tempus Gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus 
Gene panel (81162, 81191, 81206, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81404) provided on 
May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided May 13, 2020 to May 
18, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services 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 the primary diagnosis code of 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. Our reviewer says that the documentation does not support that the DRG billed is supported 
by the documentation. Our physician reviewer found the documentation supported an admission for Type 2 
diabetes mellitus with hypoglycemia without coma. The documentation was inconsistent/unclear regarding a 
diagnosis of Metabolic encephalopathy. Even though Metabolic encephalopathy is documented on history and 
physical exam, progress notes and discharge summary, supporting medical record documentation was not 
found within the record. Hospital correspondence maintains that member arrives with altered mental state and 
low blood sugar, altered mental state improved after half amp of D50; Acute metabolic encephalopathy was 
superimposed on dementia due to hypoglycemia. The enrollee presented with altered mental state and 
hypoglycemia. Emergency Medical Services noted blood sugar as low as 40, on Emergency Room was 25. The 
enrollee was given D50 and encouraged to drink orange juice. While enrollee presentation warranted 
consideration of metabolic encephalopathy there was no documentation of neurological exams consistent with 
a diagnosis of encephalopathy or diagnostic work ups done such as electroencephalogram (EEG), magnetic 
resonance imaging (MRI), computed tomography (CT), or lab tests such as blood ammonia, thiamine, or zinc 
levels to specifically validate encephalopathy. The review has determined that the DRG billed (DRG 637) was 
not supported by the documentation. The diagnosis G93.41, Metabolic encephalopathy was not supported as a 
principal diagnosis. Therefore, the services are not payable as billed.  
 
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 provided May 13, 2020 to May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin (J9045), Paclitaxel (J9267), Pembrolizumab 
(J9271), and supporting therapy (Dexamethasone Sodium Phosphate (J1100), Diphenhydramine HCL (J1200), 
Ondansetron HCL (J2405), and Famotidine (J3490)). 
 
You asked the Plan to pre-approve the Carboplatin (J9045), Paclitaxel (J9267), Pembrolizumab (J9271), and 
supporting therapy. The Plan denied your request. The Plan says the documentation provided does not support 
that the enrollee has met the criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 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 Carboplatin (J9045), Paclitaxel 
(J9267), Pembrolizumab (J9271), and supporting therapy. Our reviewer says that these drugs are not medically 
reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Carboplatin 
(J9045), Paclitaxel (J9267), Pembrolizumab (J9271), and supporting therapy are not Food and Drug 
Administration (FDA) approved for the enrollee's diagnosis. Treatment is for metastatic disease and the 
enrollee is without evidence of metastatic disease. Our reviewer found that the use of these drugs is not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & 
Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that these drugs are 
not listed as not indicated, not supported, or not recommended in any of the compendia. 
 
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 Carboplatin (J9045), Paclitaxel (J9267), Pembrolizumab (J9271), and 
supporting therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Carboplatin (J9045), Paclitaxel (J9267), Pembrolizumab (J9271), and supporting therapy (Dexamethasone 
Sodium Phosphate (J1100), Diphenhydramine HCL (J1200), Ondansetron HCL (J2405), and Famotidine 
(J3490)).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tacrolimus. 
 
You asked the Plan to pre-approve Tacrolimus. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tacrolimus.  
 
Benefits for Tacrolimus may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for end-stage renal disease services you 
received from a nephrologist from January 1, 2021, to May 31, 2021. 
 
You asked the Plan to waive the copayments for the nephrology services. You say that you should have a zero 
dollar copayment for these services. The Plan denied your request. The Plan says you were originally charged 
20% coinsurance for these services incorrectly.  These claims have been adjusted and you are now being 
charged a $30 copayment per date of service.  The Plan says that these copayments were charged 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 $30 
copayment for physician specialist services.  
 
 You have been asked to pay a $30 copayment for the nephrology services. The nephrology services falls within 
the physician specialist services 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 copayments for 
end-stage renal disease services you received from a nephrologist from January 1, 2021, to May 31, 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 enrollee is not getting the therapy he needs to 
improve. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is not stable to go home. The Plan 
denied your request. The Plan says that the services the enrollee requires can safely be received at a different 
setting. 
 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 the enrollee's condition does not 
meet Medicare criteria for SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient hospital clinic visit you had 
on January 8, 2021. 
 
You asked the Plan to waive the deductible for the outpatient hospital clinic visit. You say that the deductible 
shouldn't apply to this service because it was an in-network specialist visit. The Plan denied your request. The 
Plan says you were charged this deductible correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient hospital clinic services.  
 
Records show that you received these services at an outpatient hospital clinic, not at a specialist?s office. The 
deductible applies to outpatient hospital clinic services, as outpatient hospital clinic services are not listed 
among the services excluded from the deductible. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $750 deductible which applies to outpatient hospital clinic services. This cost 
sharing is a contractual obligation that had not been met at the time the outpatient hospital clinic visit was received on January 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the 
outpatient hospital clinic visit you had on January 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve additional home health services. You say that home health services are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says additional home 
health physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the requested home health medical services are not medically reasonable and necessary. Our 
physician reviewer found the enrollee is an 83-year-old female. She has a history of hypertension, 
hypersensitivity lung disease, and diabetes mellitus. Based on the limited documentation provided, it is my 
opinion that the health plan?s denial should be upheld. The enrollee does not have documented skilled home 
health physical therapy needs.  The enrollee is functioning at a level commiserate with a lower level of care. As 
such, the requested, ongoing, home health physical therapy is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 9 additional home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on November 
27, 2020 by a PT assistant (PTA). 
 
You asked the Plan to pay for the PTA services. You say that Texas law requires that Preferred Provider 
Organizations (PPOs) cover noncontract services at the preferred rate if there are not network providers 
available which is the case here. The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that PTA services are not covered when billed as 
incident to a NPP because an NPP does not meet the qualifications of a therapist.  
 
These services were billed by an NPP and provided by a PTA. This does not meet Medicare coverage rules. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on 
November 27, 2020 by a PT assistant (PTA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the upper left, 
upper right, and lower right quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not necessary. 
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the requested scaling and root planing is not medically necessary. Our physician reviewer found the 
provided documentation indicates that the radiographs did not show any bone loss or evidence of subgingival 
calculus formation. The reviewer found there was no documentation of charting of periodontal pockets. 
Therefore, the reviewer found that the scaling and root planing is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Specifically, the file does not indicate 
that there is bone loss in any of the quadrants. Therefore, we decided that the Plan does not have to pre-approve 
scaling and root planing (D4341) for the upper left, upper right, and lower right quadrants.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
 
  
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 Euflexxa. Our reviewer says that 
Euflexxa (J7323) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as 
outlined by the Plan, requires that these be trialed first. Our reviewer found that the documentation does not 
outline contraindications or reasons these medications were not considered or that the Plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also 
found that without the support of the documentation, Euflexxa is not approved as step criteria have 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tetanus vaccine (90715) provided May 20, 2021. 
 
You asked the Plan to pay for the vaccine. You say that the vaccine was medically necessary and should be 
covered. The Plan denied your request. The Plan says this vaccine is not eligible for Part B coverage in this 
case. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for a tetanus vaccine (90715) provided May 20, 2021.  
 
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of low back pain. The Intracept procedure is experimental. 
More research is needed to show safety and efficacy for back pain. Therefore, the enrollee does not meet 
criteria for the requested 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.