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 January 26, 2021, to 
January 28, 2021, as billed with Diagnosis Related Group (DRG) 640. 
 
You asked the Plan to pay for inpatient care billed with DRG 640. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 640 is not appropriate as the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. The 
Plan argues that DRG 641 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 640. Our 
reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee with a past medical history of 
pancreatic cancer, hyperlipidemia, urinary retention, and hypertension presented to the facility with the chief 
complaint of difficulty aphasia, weakness, confusion and being off balance. The physical exam noted the 
enrollee was well-developed with normal respiratory status and normal pulmonary effort. Neurology status was 
alert and oriented x3 with mental status at baseline. The History and Physical noted the enrollee was alert and 
oriented to self, place, and partially to time. Mood and affect were noted to be appropriate. The enrollee was 
diagnosed with urinary retention, hyponatremia, and weakness. It was noted that the enrollees weakness was 
likely in the setting of dehydration and hyponatremia, and the confusion was likely metabolic encephalopathy 
in setting of hyponatremia and dehydration. Progress notes noted the enrollees mentation appeared to be at 
baseline which was documented the day after admission. Hospital correspondence includes an excerpt from a 
query that was sent to the physician to clarify the diagnosis of metabolic encephalopathy; however, it was not 
the complete document and there were no patient identifiers noted on the query. In addition, the enrollees 
mental status was conflicting throughout the record and did not support a change in the mental status beyond 
baseline. The review has determined that the medical records did not support the billing of metabolic 
encephalopathy (G93.41). 
 
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 640 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 26, 2021, to January 28, 
2021, as billed with Diagnosis Related Group (DRG) 640.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 31, 2022, to 
April 29, 2022. 
 
You asked the Plan to pay for the services provided. You say that an NOA was accepted in January 2022. The 
Plan denied your request. The Plan says a required data element was missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that a notice of admission was not submitted within five calendar 
days after the admission date. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from March 31, 2022, to April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently confined to a wheelchair and need 
to be able to walk to take care of your daily needs. You say that you are concerned that waiting too much 
longer will make you completely lose the use of your legs. The Plan denied your request. The Plan says based 
on Medicare guidelines, the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found you were admitted for weakness, anemia, shortness of breath, and diarrhea. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room (ER) services you received on December 
28, 2020. 
 
You asked the Plan to pay for the ER services. You say that you did not receive these services. The Plan denied 
your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ER services was not filed until April 27, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for emergency room (ER) services you received on December 28, 2020.  
 
Your complaint about not receiving these services is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone and/or joint imaging (78315) of the knee area. 
 
You asked the Plan to pre-approve a bone and/or joint imaging of the knee area. The Plan denied your request. 
The Plan says the enrollee does not meet the guidelines for the requested service which does not appear 
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 pre-approve a bone and/or joint imaging of the knee 
area. Our reviewer says that the bone and/or joint imaging is not medically reasonable or necessary. Our 
physician reviewer found the requested nuclear medicine study of bone is not medically necessary, as there was 
not a documented computed tomography scan of the affected area to look for component loosening. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone and/or joint imaging of the knee area have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a bone and/or joint imaging (78315) of the knee area.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the specimen was obtained in an office setting. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 the lab services provided on January 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need additional trips due to your 
health issues. The Plan denied your request. The Plan says you have exhausted your 2022 transportation 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way, non-emergency trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage services provided on February 7, 
2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
included within the global surgery package of a previous procedure. 
 
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 22010 is incision and drainage, open, of deep abscess 
(subfascial), posterior spine; cervical, thoracic, or cervicothoracic. 
 
 We find that CPT code 22010 is not supported. The claim information shows that code 22010 is included in the 
global surgery package of code 22610. The code at issue was not billed with a modifier indicating the service 
was not related to the previous procedure. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the incision and drainage services provided on February 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary, the services you need can be provided 
safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has complex medical needs, and IRF 
will affect enrollees ability to regain max stability. The Plan denied your request. The Plan says criteria for 
admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can 
be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injection, ipilimumab, 1 mg (J9228) and Injection, 
nivolumab, 1 mg (J9299). 
 
You asked the Plan to pre-approve the injections. You say that that you are requesting reconsideration as these 
medications is medically necessary for the enrollee's treatment for kidney cancer. The Plan denied your request. 
The Plan says the use of this drug/regimen is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pre-approve the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested use of ipilimumab and nivolumab injections are not FDA-approved for the 
enrollees diagnosis. Phase III data has not matured yet to show overall survival. These drugs are not supported 
or not recommended in any of the compendia. 
 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injection, ipilimumab, 1 mg (J9228) and Injection, nivolumab, 1 mg (J9299).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry home visit provided on March 3, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physician visit. You say that you did not know that you needed a referral. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and authorization was not obtained. 
 
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 a podiatry home visit provided on March 3, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluations provided on January 12, 2022 and 
April 28, 2022, by an OON provider. 
 
You asked the Plan to pay for telephone evaluations. You say that you have been seeing this doctor for twenty 
years. You knew your RX plan was covered by one plan and did not realize your medical plan was covered by 
another. The Plan denied your request. The Plan says the out-of-network services were not authorized.  
 
 
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 telephone evaluations provided on January 12, 
2022 and April 28, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve a biopsy. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says an incisional biopsy of oral tissue (D7286) is not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
incisional biopsy of oral tissue (D7286).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have any complex nursing or rehabilitation needs. Medically 
necessary care can be provided in a different level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fitting of spectacles (92340) provided on May 5, 2022. 
 
You asked the Plan to pay for spectacle fitting. You say that you were told your insurance would cover these 
services. The Plan denied your request. The Plan says this service is not covered by your supplemental 
Medicare vision benefit. The Plan says this code is appropriate for a Medicaid plan only. The Plan also states in 
a letter dated June 30, 2022, that they confirmed with the providers office that you do not have a balance for 
this claim. 
 
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.  
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested item/service is not 
among those listed as covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the fitting of spectacles (92340) provided on May 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78830 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 78830. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 78830 is bundled into 
payment for code 79445. 
 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 78830 
is a column II code to column I code 79445. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 78830 billed for date of service April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on May 31, 2022. 
 
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says 
the total cost for the vision services was $320. $300 was covered by the members benefit allowance, leaving a 
remaining balance of $20. EyeMed provided a courtesy 20% discount off of the members $20 remaining 
balance which totaled $4 off. Therefore, the member is responsible for the remaining balance of $16 and the 
claims processed correctly. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum eyewear benefit 
allowance. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses 
provided on May 31, 2022.