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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 20, 2021 to April 
23, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care provided was 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
that the documentation provided supports an observational level of care and not an inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee is an 85-year-old female with a history of dementia, basal cell carcinoma of the 
face, constipation, Lyme disease, meibomian gland dysfunction, and varicose veins of a lower extremity who 
had a fall and a wedge compression of the L1 and L2 vertebra approximately two weeks before presenting to 
the Divine Savior Healthcare on April 20, 2021. She had tried Valium and Tylenol at home to treat the pain but 
could not tolerate the Valium and the Tylenol did not alleviate her pain. In fact, she fell one week prior to 
presenting for care and has largely been bed bound since the fall. She presented with pain to the extent that she 
could not care for herself. She was evaluated and admitted and given oral narcotics (on an as needed basis), a 
lidocaine patch for her back, and oral Tylenol for her pain. Her condition stabilized and improved and she was 
discharged home on April 23, 2021. The review has determined that the record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from April 20, 2021 to April 23, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing provided on May 10, 2021. 
 
You asked the Plan to pay for the CxBladder Detect testing. You say that this is a medically necessary test 
which should be covered. The Plan denied your request. The Plan says this is not covered per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the CxBladder assay remains noncovered as of 
the most recent review in October 2018. Therefore, we decided that the Plan does not have to pay for the 
CxBladder Detect testing provided on May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
 You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the services required can be provided in a different setting, for example, home with 
home health, in residential care, or home with close follow-up with the doctor. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found at the time of transition to a skilled level 
of care in the nursing facility, the enrollee was medically stable.  The enrollee does not require any skilled 
nursing or rehab services on a daily basis at an inpatient level of care. The enrollee was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish 
a safe and effective maintenance program.  As a practical matter, the enrollee did not require any skilled 
services on an inpatient basis, at a SNF level of care. The enrollee did not have any parental medication, 
complex wound care or nutrition given via a feeding tube.  She was medically stable without any acute 
exacerbations of chronic medical problems.  Her physical function was at or near her baseline and she could 
have received further services at a lower level of care. Admission to the nursing facility at a skilled level of 
care for inpatient skilled services was 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305, 88312) provided on June 22, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 service 
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 lab services (88305, 88312) provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis/teeth 
cleaning (D1110), and bitewings - four radiographic images (D0274). 
 
You asked the Plan to pay for the oral exam, cleaning, and dental x-rays. You say that you did not know your 
dentist is not a Medicare provider. You also say that you have limited income, and it is hard to make ends meet. 
The Plan denied your request. The Plan says you have reached the maximum amount allowed for 
reimbursement of dental benefits. The Plan paid $500 toward your dental benefit despite the provider opting 
out of Medicare because they failed to inform you about your full dental benefits. 
 
 
 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 oral exams, 
cleanings, and dental x-rays up to a benefit limit of $500. Based on the records provided, the Plan has paid all 
the benefits required by the Plan dental contract. Therefore, we decided that the Plan does not have to pay for a 
periodic oral evaluation (D0120), prophylaxis/teeth cleaning (D1110), and bitewings - four radiographic 
images (D0274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on March 23, 2021. 
 
You asked the Plan to pay for the crown. You say that the dental office projected insurance would pay up to 
$1,500 so you decided to have the additional work done. You say that any additional amount up to the annual 
benefit should be credited. The Plan denied your request. The Plan says the annual maximum has been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
$500 annually for crowns and bridges. The Plan paid $500 for the crowns provided on March 4, 2021, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the crown provided on 
March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive pharmacogenetic panel (81223, 81225, 
81227, 81226, 81241, 81328, 81335, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 81291, 
81306) provided on June 9, 2021. 
 
You asked the Plan to pay for a comprehensive pharmacogenetic panel. You say that this was medically 
necessary. 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.  If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered 
part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the 
panel. 
 
We find that CPT codes 81223, 81225, 81227, 81226, 81241, 81328, 81335, 81400, 81401, 81230, 81231, 
81240, 81232, 81406, 81350, 81479, 81291, and 81306 are not supported in the medical record. Specifically, 
these codes were used to report a panel, which should be billed with one code. Based on this information, we 
decided that Medicare rules for coverage of a comprehensive pharmacogenetic panel have not been met. 
Therefore, we decided that the Plan does not have to pay for a comprehensive pharmacogenetic panel (81223, 
81225, 81227, 81226, 81241, 81328, 81335, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 
81291, 81306) provided on June 9, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) provided on May 11, 2021. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says that the records do not show that 22 or more drug classes were tested. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that more than 
22 classes were tested. The classes tested include Amphetamines; Antidepressants, serotonergic class; 
Antidepressants, tricyclic and other cyclicals; Antidepressants, not otherwise specified Antipsychotics, not 
otherwise specified; Barbituates; Benzodizepines; Buprenorphine; Cannabinoids, synthetic; Cocaine; 
Fentanyls; Gabapentin, non-blood; Heroin metabolite; Ketamine and Norketamine; Methadone; 
Methylenedioxyamphetamines; Methylphenidate; Opiates; Opioids and opiate analogs; Oxycodone; 
Phencyclidine; Pregabalin; Propoxyphene; Sedative Hypnotics (non-benzodiazepines); Skeletal muscle 
relaxants; Stimulants, synthetic; Tapentadol; and Tramadol.  Based on this information, we decided that 
Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for 
drug testing (G0483) provided on May 11, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 7, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the 
enrollee on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided June 11, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that liquid biopsies are covered for a patient that has 
decided to seek further cancer treatment. 
 
We looked at the file and Medicare rules. The record shows the enrollee is pursuing surveillance only and no 
further treatment. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) 
provided June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (procedure code 72170) provided to the 
enrollee on June 17, 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 appropriate modifier was not billed in this case. 
 
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 72170 is "Radiologic examination, pelvis; 1 or 2 views." 
 
We find that CPT code 72170 is not supported in the medical record. Specifically, this code cannot be paid 
separately in this case without the appropriate modifier. 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 imaging services (procedure code 72170) provided to the enrollee on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on May 13, 2021. 
 
You asked the Plan to pay for code 0013M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0013M) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitored anesthesia billed to the enrollee for May 12, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare coverage criteria are not 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 pay for these services. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found According to the American Society of Anesthesiologists (ASA), monitored 
anesthesia care (MAC) is a planned procedure during which the patient undergoes local anesthesia together 
with sedation and analgesia.  The review has determined that this enrollee does not have a diagnosis, condition, 
and/or symptoms that meet the Medicare criteria for coverage of MAC.   
 Some factors or significant medical conditions may include any of the following: Patients with potential for 
difficult intubation and/or ventilation with a mask, or at risk for airway obstruction; Increased risk for 
complication due to severe co-morbidity: ASA Class III physical status or greater (Class III ASA is defined as 
severe systemic disease that limits activity, but is not incapacitating, e.g., stable angina, history of myocardial 
infarction, history of stroke, insulin dependent diabetes, poorly controlled disorders, e.g., hypertension, asthma, 
psychiatric disorders, dysrhythmias, congestive heart failure, chronic obstructive pulmonary disease); Patients 
with chronic degenerative neurologic diseases which may cause difficulty swallowing or pose a risk for muscle 
weakness and respiratory failure; Morbid obesity (body mass index great than 50); or Extremes of age, i.e., 
greater than 70 years of age or less than 18.  In this case, the procedure does not generally require monitored 
anesthesia care and the available medical records provide no evidence of comorbidity or other clinical 
circumstance that indicates a need for monitored anesthesia care. The review has determined that the requested 
anesthesia service 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for monitored anesthesia billed to the enrollee for May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded as 75710 and 75625 provided on 
March 1, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like these services reprocessed 
based on the medical documentation provided. The Plan denied your request. The Plan says the documentation 
does not support the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 medical services.  
 
 Our reviewer says that the documentation does not support the services as billed. Our reviewer found regarding 
procedure 75710 billed with an XU modifier, the procedure report does not include documentation of an 
angiography, extremity, radiological supervision, and interpretation. Unable to cite report as this procedure was 
not documented, and therefore this procedure and modifier cannot be confirmed as performed. Regarding 
75625, the procedure report does not include documentation of aortography, abdominal by serialography, 
radiological supervision and interpretation.  Unable to site report, as this procedure was not documented and 
therefore cannot be verified as performed. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded as 75710 and 75625 provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care services (procedure code 99217) provided 
to the enrollee on June 30, 2021. 
 
You asked the Plan to pay for the servcies. You say that this should be paid for. The Plan denied your request. 
The Plan says a qualifying initial or subsequent observation care service was not found in the claims history. 
 
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 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status.." 
 
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 servcies. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation was thoroughly 
reviewed, and did not include observation care notes to confirm that correct billing had occurred. 
 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 servcies have not been met. Therefore, we decided that the Plan does not 
have to pay for observation care services (procedure code 99217) provided to the enrollee on June 30, 2021.