Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional non-emergency transportation; per diem 
(T2002). 
 
You asked the Plan to pre-approve 3 additional transportation. You say that you recently had major surgery and 
need the additional transportation for your physical therapy visits. You do not have any other way to get to 
these appointments. The Plan denied your request. The Plan says this request for more transportation benefits 
goes beyond the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips to other health care related locations trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 3 additional non-emergency transportation; per diem 
(T2002).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 5, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the drug testing services provided on May 5, 2022 by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from February 21, 2021, to 
March 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not 
supported. 
 
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 A41.9. 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 use of diagnosis code A41.9 is 
not supported by the records provided. Our physician reviewer found that the enrollee is 76-year-old female 
who was admitted and treated in the hospital for acute heart failure with fever. Liver enzymes were elevated 
and thought to be related to the hepatic congestion related to the heart failure. She was noted to have confusion, 
but she had a history of dementia near her baseline. She did require oxygen related to pulmonary edema which 
was treated with diuresis. When all these and other normal testing were calculated, and following ED 
treatment, the enrollee had a SOFA score of 0 on admission and during the hospitalization. The documentation 
did not clearly show evidence of a systemic infection that was causing organ dysfunction as required for Sepsis 
3 criteria. Therefore, the documentation does not sufficiently support the diagnosis of sepsis.  
 
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 February 21, 2021, to March 3, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for oncology (breast), gene expression profiling (81518) billed for date of 
service March 4, 2022. 
 
You asked the Plan to pay for gene expression profiling. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this claim was billed with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory tests should be billed with the 
date of specimen collection as the date of service. However, there are three exceptions to this rule. The rules 
also 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. 
 
Although laboratory services should generally be billed with the date of service of the collection, there are 
exceptions to the rule. Because the specimen at issue is part of a solid tumor which was collected during a 
hospital procedure, it is highly likely that an exception has been met which would make the correct date of 
service the date of testing. This exception requires that the specimen be collected in a hospital setting as part of 
a procedure which would be inappropriate to receive in another setting/at another time (biopsy), and the results 
of the testing in question should not have a clinical impact on the hospital care at the time of collection. It 
appears that this exception has been met in this case; however, the Plan has neither acknowledged that there are 
exceptions to this rule nor provided any evidence to show that they do not apply in this case. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for oncology (breast), gene expression profiling 
(81518) billed for date of service March 4, 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 pre-approve computer-assisted navigation for a total hip arthroplasty 
surgery. 
 
You asked the Plan to pre-approve computer-assisted navigation. You say that the enrollee is in extreme pain. 
The Plan denied your request. The Plan says there are no studies confirming the benefits of computer-assisted 
surgery over standard surgical approaches in total hip arthroplasty. 
 
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 computer-assisted navigation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the clinical benefits, including ultimate outcomes of functional 
improvement and pain reduction, with computer navigation over standard surgery is not evident in large-scale, 
long-term, peer-reviewed literature. There is no compelling rationale or extenuating circumstance noted to 
support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted navigation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computer-assisted navigation for a total hip arthroplasty surgery.
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 
March 8, 2021, to March 12, 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 the DRG was updated in this case.  
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 280. 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 services at issue in this case were not 
supported by the medical records. Our physician reviewer found that the provider has noted an elevated BNP of 
752 to support the condition, however, this finding alone would not validate the condition of 17, Spo2 was 
97%, and lungs were clear to auscultation. The history and physical also noted no apparent distress. The review 
has determined that the records did not support the use of diagnosis code I50.43 in this case. The records 
support DRG 281 in this case.  
 
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 March 8, 2021, to March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an 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 intracept procedure is experimental for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure, thermal destruction of 
intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral 
(64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for the wrongful 
denial for Intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says this procedure is considered experimental and investigational as it 
is not an accepted standard of medical practice for the diagnosis or treatment of back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure, thermal destruction of intraosseous basivertebral nerve, including all 
imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on March 25, 
2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that there should be no copayment 
for follow-up visits. The Plan denied your request. The Plan says this cost sharing was 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 services obtained from a specialist. 
 
 
 
 
 
 
 
 You have been asked to pay a $30 copayment for the specialist visit. This item/service falls within the services 
obtained from a specialist 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 
specialist visit provided on March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on March 7, 2022. 
 
You asked the Plan to pay for the provided items. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the documentation did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state if the information in the patients medical record does not 
adequately support the medical necessity for the item, the supplier is liable for the dollar amount.  
 
The record does not contain relevant medical records which support medical necessity for the supplies in this 
case. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the durable medical equipment provided on March 7, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a SNF stay provided from February 1, 2020, to 
February 20, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you feel that you should not owe 
anything for your Skilled Nursing Facility stay. You say that the extended stay was due to the negligence of the 
facility. The Plan denied your request. The Plan says that the copayment applied is correct. 
 
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. The Plan did not provide documentation showing the exact number of Skilled 
Nursing Facility (SNF) days that were applied to this benefit period. This means we are unable to calculate the 
total number of days spent in a Skilled Nursing Facility to determine the cost you are being asked to pay is 
correct. Therefore, we decided that the Plan has to waive the copayment for a SNF stay provided from 
February 1, 2020, to February 20, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 27, 
2022. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 32555. 
 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 71045 
is a column II code to column I code 32555. 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 procedure code 71045 billed for date of service February 27, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from September 4, 2021, to 
September 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not 
supported. 
 
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 A41.9. 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 use of diagnosis code A41.9 is 
not supported by the records provided. Our physician reviewer found that there were no clear signs or 
symptoms of organ dysfunction as a result of the infection and the Sepsis 3 criteria was not met as the SOFA 
points did not raise. Therefore, the provided documentation does not sufficiently support sepsis as a diagnosis.  
 
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 September 4, 2021, to September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair ramps. 
 
You asked the Plan to pre-approve wheelchair ramps. You say that you do not want to be stuck in the house 
because you do not have the ramps. The Plan denied your request. The Plan says that wheelchair ramps do not 
serve a medical purpose and are not appropriate for use in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve wheelchair ramps.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service May 13, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70480 is bundled into payment for code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 procedure code 70480 billed for date of service May 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. The 
record as provided is insufficient to determine that the enrollee has tried and failed conservative 
nonpharmacologic treatment such as physical therapy or simple analgesics. The records indicate he may have 
received viscosupplementation in the past but does not indicate results or when received. The Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition in this 
specific scenario. The Medicare-approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have weakness in 
your right side (hemiplegia) and history of a traumatic brain injury. You are not using a ventilator, intermittent 
catheterization, and do not have skin issues. The criteria for coverage of the Group 3 PWC are not met; 
therefore, the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC).