Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on April 19, 2022 to April 
22, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 find that CPT code 99213 is not supported in the medical record. Specifically, the claim was billed with 
place of service 22, outpatient hospital. Office visit evaluation and management codes cannot be paid for 
services provided in an emergency room, hospital observation, or for hospital inpatients. Based on this 
information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (99213) provided on April 19, 2022 to April 22, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 9, 2021, to 
March 18, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation supports diagnosis codes A41.9, J18.9 and J44.0 and the denial should be overturned. The Plan 
denied your request. The Plan says diagnosis codes A41.9, J18.9 and J44.0 are 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 codes A41.9, J18.9 and J44.0 defined as, 
sepsis, unspecified organism, pneumonia due to other infectious organisms, not elsewhere classified, and 
chronic obstructive pulmonary disease with acute lower respiratory infection. 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 documentation does not support diagnosis codes A41.9, J18.9 and J44.0. Our physician reviewer found 
the enrollee was diagnosed with acute chronic obstructive pulmonary disease with exacerbation and treated 
with intravenous antibiotics, nebulizers, and oxygen. The enrollee's chest x-ray showed pleural effusions and 
was without any evidence of pneumonia.  
 
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 from March 9, 2021, to March 18, 2021, at the DRG originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on March 16, 2022, billed with code 
L0625. 
 
You asked the Plan to pay for the back brace. You say that this was incorrectly denied as a duplicate claim. The 
corrected claim was billed with modifier CG and should be paid. The Plan denied your request. The Plan says 
the enrollee received this same item within five years and is not eligible for a new brace. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the supplier was reimbursed for the same code for date of service March 11, 2022. This 
brace serves the same purpose as the brace at issue in this appeal. There is no evidence that more than one 
brace was ordered or provided. As such, we find that the denial of this claim is supported. Therefore, we 
decided that the Plan does not have to pay for the back brace provided on March 16, 2022, billed with code 
L0625.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services received from January 20, 
2022, to March 31, 2022. 
 
You asked the Plan to pay for the services. You say that you were informed that the plan would pay 60% of the 
total charge. The Plan denied your request. The Plan says you were aware that the provider opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services received from January 20, 2022, to March 31, 2022.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to still be unstable and should only require short-term additional 
acute care services that can safely be administered at the current facility until more stable and appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet 
stable for transfer and as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is recommended. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided April 22, 2022. 
 
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 the documentation does not support the billed services. 
 
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 find that CPT code 81479 is not supported in the medical record. Specifically, records show the specimens 
were collected on August 18, 2021 and April 5, 2022. This does not match the billed date of service. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (81479) provided April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 3, 
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 provider did not bill as required by Medicare coding regulations. 
 
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 13101: 
 
Repair, complex, trunk; 2.6 cm to 7.5 cm 
 
CPT 15100: 
 
Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 
(except 15050) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that multiple units of CPT 13101 and 15100 were rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested item is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
documentation doesnt support that you have a condition that requires frequent positioning of the bed and 
mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in 
a way that an ordinary bed is not able to. 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition could cause 
health decline and re-hospitalization. The Plan denied your request. The Plan says the clinical effectiveness has 
not been demonstrated in peer-reviewed literature. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). There remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for golimumab (J1602) provided from 
September 9, 2021, to January 9, 2022. 
 
You asked the Plan to pay an additional amount for golimumab. You say that you are being discriminated 
because of your weight. You say that you were given the correct dosage based on your weight. You also say 
that the recoupment should be repaid to the provider. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 pay an additional amount for golimumab. Our 
reviewer says that the additional units of golimumab is not medically necessary. Our physician reviewer found 
the dosage of Golimumab in this case is not FDA-approved for your diagnosis. The reviewer also found that 
the dosage provided in this case is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). Therefore, 
the reviewer found that the additional units of golimumab are not medically reasonable and 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 golimumab have not been met. Therefore, we decided that the Plan does not 
have to pay an additional amount for golimumab (J1602) provided from September 9, 2021, to January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on March 25, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. However, the Plan offers a chiropractic benefit that 
exceeds Medicare coverage. The Plan provides coverage for spine x-rays and chiropractic radiology services.  
 
Although the Plan offers a chiropractic benefit in excess of Medicare coverage, the service provided is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the office 
visit (99204) provided on March 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 18, 2022, to 
January 22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
secondary diagnosis of N17.0 (acute kidney failure with tubular necrosis) is supported in the medical 
record.and was billed appropriately. The Plan denied your request. The Plan says the secondary diagnosis of 
N17.0 (acute kidney failure with tubular necrosis) is not supported in the medical record. 
 
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 secondary diagnosis of N17.0 (acute kidney 
failure with tubular necrosis). We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that [state physician reviewer's conclusion, 
e.g. "the service is not medically necessary." or "you need this medical item."] Our physician reviewer found a 
nephrology consultation was obtained on January 19, 2022, and the records from that consult stated the patient 
had weakness and diarrhea. Nephrology was consulted for abnormal renal function and electrolyte profile. The 
nephrology notes included a diagnosis of acute kidney infection (AKI) suspected secondary to vasomotor 
nephropathy versus acute tubular necrosis (ATN). While it was noted that the provider diagnosed vasomotor 
nephropathy and that the ICD-10-CM Index to Diseases and Injuries directs the user to apply code N17.0 
(acute kidney failure with tubular necrosis) to vasomotor nephropathy, the clinical documentation did not 
sufficiently support a diagnosis of acute kidney failure with tubular necrosis (ATN).  
 
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 on January 18, 2022, to January 22, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service February 5, 2022. 
 
You asked the Plan to pay for code 99223. You say that these services were medically necessary and 
reasonable and billed appropriately as this patient was high-risk. The Plan denied your request. The Plan says 
code 99223 is not supported, and it appears this is upcoding. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: A comprehensive history. A 
comprehensive exam. Medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not 
supported in the medical record. Our reviewer found the enrollee was a then 51 yo male with a history of insulin-dependent diabetes mellitus and congestive heart failure (Ejection Fraction of 30%), asthma, anxiety 
and chronic kidney disease Stage III who was admitted on February 5, 2022, with weakness , hypotension and 
increased creatinine to 3.0 one week after initiation of Entresto therapy. He was treated with IV fluids and 
evaluated by Nephrology. The review has determined that the documentation did not support procedure code 
99223. Specifically, there was no medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service February 5, 2022.  
 
Please note that billed for G8427 was not billed with a dollar amount, and it does not appear that you are requesting any 
additional payment for that code.  Therefore, this review is not addressing that code.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional screening mammography (77067) provided on 
May 7, 2021. 
 
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says this service was billed twice on this date of service. 
 
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 77067 is "screening mammography, bilateral (2-view 
study of each breast), including computer-aided detection (CAD) when performed." 
 We find that an additional CPT code 77067 is not supported in the medical record. Specifically, the 
mammography reports that were included in the case file were duplicates of each other. 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 an additional screening mammography (77067) provided on May 
7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care, per day (99231) rendered by the 
out-of-network (OON) provider on May 18, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent hospital care, per day (99231) rendered by the out-of-network (OON) 
provider on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing provided on March 30, 2022. 
 
You asked the Plan to pay for the PrismRA testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that testing must be FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA testing at issue in this appeal is not 
FDA approved. Based on this information, we decided that Medicare rules for coverage of the PrismRA testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA testing provided 
on March 30, 2022.