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

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 12, 2021, to June 
21, 2021, as billed with Diagnosis Related Group (DRG) 177. 
 
You asked the Plan to pay for inpatient care billed with DRG 177. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 177 is not supported as the diagnosis of pneumonia due to other gram-negative bacteria (J15.6) is not supported in the 
medical record. The Plan argues that DRG 193 is more appropriate in this case, as the principal diagnosis is 
best reported as pneumonia, unspecified organism (J18.9). 
 
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. 
 
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 inpatient care billed with DRG 177. Our 
reviewer says that the diagnosis of pneumonia due to other gram-negative bacteria (J15.6) is not supported in 
the medical record. Our physician reviewer found that the documentation supports an admission for 
pneumonia, unspecified organism (J18.9). Even though "pneumonia, likely gram negative" was documented in 
progress notes, supporting documentation was not found within the submitted medical record. A diagnosis of 
gram-negative pneumonia cannot be made on the basis of clinical signs and symptoms, or risk factors, due to 
the overlap with other types of pneumonia. Coding this should be supported by confirmatory data. One of the 
following is needed to support gram negative pneumonia: a sputum gram stain, sputum culture or blood culture 
growing a gram-negative organism that is a pulmonary pathogen, or a positive urine antigen test for Legionella 
(which is a gram-negative organism). Documentation states Strep, Legionella and Mycoplasma antigens were 
negative. As noted above, although the provider documented pneumonia due to other gram-negative bacteria 
(J15.6), reasonable support within the health record was not present for that diagnosis. The review has 
determined that the medical records did not support the billing of pneumonia due to other gram-negative 
bacteria (J15.6). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 177 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from June 12, 2021, to June 21, 2021, as 
billed with Diagnosis Related Group (DRG) 177.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eye exam (92004) provided by a specialist on 
January 17, 2022. 
 You asked the Plan to pay more for the eye exam. You say that you paid $25 which is what is listed on your 
card for a copay. You also say that you do not owe the extra $5 for seeing a specialist. The Plan denied your 
request. The Plan says you were charged the correct $30 copayment. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says that you must pay a $30 copayment for each Medicare-covered exam with a 
specialist. 
 
We looked at the file and the Plan's rules. The 2022 Evidence of Coverage clearly states that you are 
responsible for a $30 copayment for being seen by a specialist. Based on this information, we decided that the 
Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have 
to pay more for the eye exam (92004) provided by a specialist on January 17, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the dialysis services (A4657, A4913, 90999, 83036) provided from 
January 4, 2021, to January 29, 2021. 
 
You asked the Plan to pay for the dialysis services. You say that this claim was billed appropriately, and these 
services should be paid. The Plan denied your request. The Plan says that the procedure code/bill type is 
inconsistent with the place of service. 
 
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 rules also say that all facilities which provide dialysis services, such as Hospital-Based Chronic 
Renal Dialysis Facilities, should use their appropriately assigned NPI numbers on the 72x type bill. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provider in this case is indicated as a Chronic Renal Dialysis Facility 
(Hospital-Based), and the type of bill indicated on this claim is 721. The Plan has not provided any further 
information or citations to support their denial of this claim. Therefore, we decided that the Plan has to pay for 
the dialysis services (A4657, A4913, 90999, 83036) provided from January 4, 2021, to January 29, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the therapeutic injection (Medicare Part B 
drug) provided on February 16, 2021. 
 
You asked the Plan to waive the coinsurance for a therapeutic injection. You say that this bill should be written 
off. The Plan denied your request. The Plan says the coinsurance was applied 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, when 
in-network,  20% coinsurance for Part B drugs, including chemotherapy drugs, drugs that usually arent self- 
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. 
  You have been asked to pay a total of $915 (allowed amount= $4,575 x 20%) for the therapeutic injection. A 
therapeutic injection falls within the Medicare Part B prescription drugs 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 coinsurance for the therapeutic injection (a Medicare Part B drug) provided on 
February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of an 
upper extremity provided on October 21, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you are on a fixed income and 
cannot afford all of the bills. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $225 
copayment for advanced radiology services, such as CT scans.  
 
You have been asked to pay a total of $196.57, which is less than the $225 copayment for the CT scan. The CT 
scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a computed tomography (CT) scan of an upper extremity 
provided on October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scoliosis repair procedure. 
 
You asked the Plan to pre-approve the scoliosis repair. You say that the enrollee would benefit from this 
procedure. The Plan denied your request. The Plan says the requested procedure is not shown to be medically 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scoliosis repair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this 73-year-old female was being treated for other spondylopathies; radiculopathy, 
lumbar region; pain in the right thigh; and hallux rigidus. She presented with chronic low back pain that has 
been progressing over the past year. Her pain is more pronounced on the left side of her back, and some up in 
the thoracic area. She has some occasional pain around the hips, left worse than right. She has neuropathy in 
her feet (and takes gabapentin for this). There is increased pain with any prolonged activity (such as standing, 
sitting, and walking). She has a difficult time sleeping as well. The exam reveals left paraspinal tenderness. 
There is intact strength and sensation.  
However, detailed documentation is not evident regarding the degree of scoliosis of the lumbar spine. The 
imaging studies provided indicated there is a leftward scoliosis apex at L3 (with no pathological subluxation 
per the CT scan and left convexity lumbar scoliosis on the x-rays). Large-scale, long-term peer-reviewed 
literature supports that further information (including instability or lack thereof) is needed prior to undergoing 
surgery to correct scoliosis. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the requested scoliosis 
repair at issue, in this case, 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 
Medicare rules for coverage of the scoliosis repair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a scoliosis repair procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted procedure, dentoalveolar structures (41899) 
provided October 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that please reconsider payment for 41899 for 
$5043.75, as this met medical necessity. The Plan denied your request. The Plan says the services provided is 
not covered under the Plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for unlisted 
procedure, dentoalveolar structures (41899) provided October 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 submitted records show that the 
home health aide services are being requested for routine assistance in the evening and at night. The enrollee's 
needs are custodial in nature. The services are not reasonable or medically necessary for the treatment of an 
illness or injury by skilled professional staff. The home health aide 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 home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on October 10, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
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 99222 
is a column II code to column I code 93018. 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 the initial hospital care rendered on October 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 22, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 22, 2021 have been met. The Plan has not received the required clinical records to support the 
medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does not 
have to pay for an epidural injection provided on November 22, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for selective catheter placement into a chest or arm artery (36215) provided 
on June 10, 2021. 
 
You asked the Plan to pay for selective catheter placement into a chest or arm artery. You say that the service 
at issue was billed correctly. The Plan denied your request. The Plan says that the available records do not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 36215 is "Selective catheter placement, arterial system; each first order thoracic or brachiocephalic 
branch, within a vascular family." 
 
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 selective catheter placement into a chest or arm artery. Our 
reviewer says that the CPT code at issue meets criteria for reimbursement. Our reviewer found that the general 
guidance for this procedure code is that it is used for insertion of a catheter into a chest or arm artery. The 
available clinical information supports procedure code 36215 for the date of service at issue. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement into a chest or arm artery have been met. 
Therefore, we decided that the Plan has to pay for selective catheter placement into a chest or arm artery 
(36215) provided on June 10, 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 Multianalyte Assays with Algorithmic Analyses (0012M) 
provided October 21, 2021. 
 
You asked the Plan to pay for CxBladder detect. You say that you appreciate prompt review of this information 
and authorization of coverage for the CxBladder detect test for this enrollee. The Plan denied your request. The 
Plan says CxBladder detect test does not meet Medicare's criteria of being medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder detect have not been met. Therefore, we decided that the Plan does not have to pay for 
Multianalyte Assays with Algorithmic Analyses (0012M) provided October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on January 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty package (K0108) and wheels (E2218) for 
a wheelchair. 
 
You asked the Plan to pre-approve the heavy-duty package and wheels. You say that these accessories are 
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 a complete manual wheelchair base includes 
propulsion wheels. Medicare rules also state that a heavy-duty wheelchair is covered if the beneficiary weighs 
more than 250 pounds or the beneficiary has severe spasticity. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The manual wheelchair base already includes propulsion wheels. The 
record does not show that the beneficiary weighs more than 250 pounds. Based on this information, we decided 
that Medicare rules for coverage of the heavy-duty package and wheels have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty package (K0108) and wheels (E2218) for a 
wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for An esophagogastroduodenoscopy on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for esophagogastroduodenoscopy. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $400 
copayment for esophagogastroduodenoscopy.  
 
You have been asked to pay a $400 copayment for esophagogastroduodenoscopy. 
esophagogastroduodenoscopy falls within the Outpatient Surgery and Other Medical Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 An esophagogastroduodenoscopy on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bone Marrow testing provided on August 5, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Bone Marrow testing. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 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 Bone Marrow testing provided on August 5, 2021 
by an out-of-network (OON) provider.