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

 
We decided that the Plan does not have to pay for the post stabilization care provided on October 30, 2021. 
 
You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration because 
the post stabilization care was medically necessary. The Plan denied your request. The Plan says the enrollee 
was stable for transfer to a plan facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a 
plan facility after the emergency room evaluation. The post-stabilization care services at the non-plan facility 
were not medically necessary or reasonable. Our physician reviewer found the treating physician did not 
document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any 
dates of service. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post stabilization care provided on October 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance billed for a continuous glucose monitor 
(code K0553) provided on March 11, 2021. 
 
You asked the Plan to pay for code K0553. You say that this claim was denied in error because you submitted 
evidence that the patient met coverage criteria. The Plan denied your request. The Plan says there is evidence 
that these items/service are misrepresented. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.  
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 code K0553. Our reviewer says that the 
patient didn't meet criteria for a continuous glucose monitor itself. Our physician reviewer found as of the 
last information provided in February of 2021, the patient is only taking Lantus insulin once daily and she is 
not taking other medications for her diabetes. The rules require multiple shots of insulin per day that are 
adjusted based on blood glucose levels. This does not mean that a continuous glucose monitor would not 
benefit her, but does mean that criteria for coverage are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code K0553 have not been met. Therefore, we decided that the Plan does not 
have to pay for the supply allowance billed for a continuous glucose monitor (code K0553) provided on March 
11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 11, 
2021. 
 
You asked the Plan to waive the copayment for a Podiatry office visit. You say that the providers involved will 
not submit the claims to your secondary insurance. The Plan denied your request. The Plan says the copayment 
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 a $60 
copayment for each out-of-network visit for Podiatry services.  
 You have only been asked to pay $34.89 for the Podiatry office visit. The allowed amount was only $34.89 so 
the Plan is only charging you the $34.89 instead of the $60 standard copayment. A Podiatry office visit falls 
within the Podiatry services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the Podiatry 
office visit provided on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
October 22, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says the services could have been provided at a lower 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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show 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 not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you have limited movement and pain 
when you are out of alignment and chiropractic adjustments are the only treatments that gives relief. You say 
that chiropractic visits should be reinstated so you have a better quality of life. The Plan denied your request. 
The Plan says your records do not report that your symptoms impact your daily tasks enough to need this type 
of treatment. 
 
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.  
 
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 chiropractic services Our reviewer says 
that the elements of the coverage criteria are not satisfied, and the requested service is not recommended. Our 
physician reviewer found the record indicates that you have mild neck and low back tightness discomfort. The 
record does not indicate the presence of a significant neuromusculoskeletal health problem. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization care provided onJanuary 14, 2022, 
through January 15, 2022. 
 
You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration because 
the hospital services were medically necessary. The Plan denied your request. The Plan says the enrollee was 
kept in observation status at the out-of-network hospital longer than medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with 
monitoring to a Plan facility prior to admission. The post-stabilization care services at the nonPlan facility were 
not medically necessary or reasonable. Our physician reviewer found the treating physician did not document 
(in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of 
service. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post stabilization care provided onJanuary 14, 2022, through January 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine protein/creatinine ratio (PCR) panel provided on 
December 16, 2021. 
 
You asked the Plan to pay for the urine PCR panel. You say that the test performed is preferred over traditional 
culture because the results are available within 24 hours. The Plan denied your request. The Plan says urine 
PCR is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the urine PCR panel. Our reviewer says that 
the urine PCR panel is not considered medically reasonable and necessary in this case. Our physician reviewer found urine PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results 
may also be challenging. Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of 
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine protein/creatinine ratio (PCR) panel provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00811-33) provided to 
the enrollee on November 10, 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 procedure code 00811 is disallowed with the modifier -33. 
 
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 00811 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified." 
 
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 the anesthesia services were 
performed for a diagnostic colonoscopy with removal of tumor, poly or other lesions. In this case, modifier 33 
preventative services would not be appropriate to report for the colonoscopy procedure reported. 
 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 anesthesia services (procedure code 00811-33) provided to the enrollee on November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on March 9, 2021. 
 
You asked the Plan to pay for the CxBladder testing. You say that this testing is medically necessary and 
should be covered. The Plan denied your request. The Plan says this testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that biomarker testing is covered when medically 
necessary for the treatment of the specific patient. 
 
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 CxBladder testing. Our reviewer says 
that the CxBladder testing is not medically necessary. Our physician reviewer found CxBladder is considered 
experimental/investigational as a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible 
biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary 
biomarker tests such as CxBladder give significant false-negative results in patients with urothelial cancer and 
are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors.   
 
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 CxBladder testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the CxBladder testing provided on March 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 5, 2021, to January 17, 2021, and an echocardiography (93306) provided on January 11, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care and echocardiography. You say that 
the services should be covered as you disagree with the charges. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services provided. 
 
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 $350 
copayment per day for days 1-5 of Inpatient hospital care and a $110 copayment for Outpatient diagnostic tests 
and therapeutic services and supplies.  
You have been asked to pay a $1,750 copayment for 5 days of inpatient hospital care ($350 x 5 = $1,750) and a 
$110 copayment for the echocardiography. 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 inpatient 
hospital care provided from January 5, 2021, to January 17, 2021, and an echocardiography (93306) provided 
on January 11, 2022.
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 May 
11, 2021, to May 14, 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 from 871 to 690.  
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 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 the reported DRG 871 is not reasonably and consistently supported by the 
documentation submitted. Although sepsis is listed in the diagnosis on each visit, no definitive diagnosis with 
plan of treatment documented, and therefore cannot be verified. The documentation is not reasonably 
consistent throughout this hospital stay. For date of service May 14, 2021 evaluation and management has this 
diagnosis listed under "Hospital problems", however, under "Resolved problems" documentation states "no 
resolved problems." In this case, this diagnosis cannot be verified.  
 
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 May 11, 2021, to May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve miscellaneous durable medical equipment, wheelchair 
ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that it is impossible to enter and/or exit your 
home in a wheelchair without a ramp. The Plan denied your request. The Plan says a ramp for the outside of the 
house is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve miscellaneous durable medical equipment, wheelchair ramp 
(E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is supported as an appropriate 
intervention and is reasonably and medically necessary as recognized by medical communities and key opinion 
leaders in rehabilitation. The Plan denied your request. The Plan says this item is considered experimental and 
investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis. 
 
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 orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that you take insulin 3 times a day 
and you check your insulin levels throughout the day. You also say you need the CGM monitoring system 
because you are unable to continue to prick your fingers and monitor your levels overnight. You are not able to 
maintain your A1C levels. The Plan denied your request. The Plan says you do not meet prior authorization 
criteria. The Plan also says additional information was requested from your physician but not received. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting that you perform blood glucose testing at least four times per day or use insulin with at least three 
daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390). You asked the Plan to pre-approve an oxygen concentrator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the enrollee has exhausted his 36 monthly rental 
payments for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oxygen concentrator have not been met. The records show that the enrollee began a monthly 
rental of an oxygen concentrator in December 2015. Specifically, the enrollee has exhausted his 36 monthly 
rental. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on February 1, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you would like to appeal the cost share 
charges for services you received. The Plan denied your request. The Plan says copayment 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 $300 
copayment for Medicare-covered, diagnostic radiology services (not including x-rays).  
 
You have been asked to pay $213.55, which is less than the standard $300 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 the CT scan provided on February 1, 2022.