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

 
We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related 
group (DRG) code 871. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that the diagnosis 
of sepsis is clinically supported by the clinical evidence in the medical record and physician documentation. 
The Plan denied your request. The Plan says DRG 871 is not supported as the diagnosis of sepsis, unspecified 
organism. 
 
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 principal diagnosis code, A41.9, defined as Sepsis, 
unspecified organism. 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 billed with DRG 871. Our reviewer says that the submitted DRG is not supported. Our physician 
reviewer found there is no documentation of hypotension or hemodynamic instability.  
 
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 the inpatient hospital services billed with diagnosis related group (DRG) code 871.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different 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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you have fallen multiple times and 
cannot walk. The Plan denied your request. The Plan says rules for power mobility devices have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane, or manual wheelchair and that you 
cannot safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power 
operated vehicle (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging (78452) 
provided on June 8, 2021. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that no one advised 
you that you would owe the copayment at issue. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
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 imaging services (not including X-rays).  
 
You have been asked to pay a $225 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging 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 myocardial perfusion imaging (78452) provided on June 8, 
2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the toe filler shoe insert (code L5000) you received 
on April 30, 2021. 
 
You asked the Plan to waive the coinsurance for the toe filler shoe insert. You say that you have never had to 
pay anything for your diabetic footwear. The Plan denied your request. The Plan says that you were charged 
this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for diabetic shoes and inserts.  
 
The Plan says you must pay 20% coinsurance for the shoe insert your received because it is considered a 
prosthetic. We do not find this argument persuasive.  Records show that on this date of service, you received 
diabetic shoes (code A5500) and diabetic inserts (code A5514) in addition to the toe filler (L5000). Clearly, all 
of these footwear items are related to diabetic foot disease.  Your contract explicitly states that you pay $0 for 
therapeutic shoes and inserts for diabetes.  Medicare rules state that when billing for diabetic toe fillers, 
providers must bill code L5000.  Just because L5000 may also be the code used for a non-diabetic toe filler 
does not mean that the Plan can charge cost sharing for this item.  An enrollee would reasonably expect that no 
cost sharing would apply to this diabetic toe filler based on the language of the contract. This item is clearly a 
diabetic foot insert which is covered at 100%, so no cost sharing should apply. Therefore, we decided that the 
Plan has to waive the coinsurance for the toe filler shoe insert (code L5000) you received on April 30, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the duplex scan with an out-of-network provider. 
 
You asked the Plan to pre-approve the duplex scan. You say that the testing is appropriate and medically 
necessary to rule out transient ischemic attack. You say that the denial should be overturned. The Plan denied 
your request. The Plan says services are available in-network. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 duplex scan. Our reviewer says that 
the member had already undergone a magnetic resonance imaging for this problem while in Puerto Rico. Our 
physician reviewer found that a carotid ultrasound is a standard procedure in the evaluation of a transient 
ischemic attack. Our reviewer says that there is not an indication as to why the member could not have 
undergone this testing prior to leaving their service area.  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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the duplex scan with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric services rendered from August 31, 2020 to 
September 30, 2020. 
 
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 that the services are not covered. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It is noted that the Plan did not make a determination by the required time frame; 
however, there is no documentation of an initial denial reason for these services. There is no documentation or 
explanation to support that the services cannot be covered, per Medicare rules. Therefore, we decided that the 
Plan has to pay for the inpatient psychiatric services rendered from August 31, 2020 to September 30, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit provided on June 28, 2021. 
 
You asked the Plan to waive the cost share for the services provided. You say that medical issues related to the 
coronavirus should be covered under the benefit plan. The Plan denied your request. The Plan says the cost 
share cannot be waived. 
 
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 10% of 
the approved amount.  
 
The file shows that you received care for acid reflux. This condition is not related to coronavirus. The services 
fall within the online visits 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 cost share for the office visit provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment exceeding the allowable amount for the 
contact lenses, scleral, gas permeable (V2531) provided June 21, 2021. 
 
You asked the Plan to provide additional payment exceeding the allowable amount for the contact lenses. You 
say that the contact lenses are medically necessary. The Plan denied your request. The Plan says the contact 
lenses are not covered under your medical benefit. No additional payment is due. 
 
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 covers these services up to a $100 maximum benefit. 
 
We looked at the file and the Plan's rules. The Plan has provided documentation showing that the vision benefit 
has been applied correctly to this claim. Therefore, we decided that the Plan does not have to provide additional 
payment exceeding the allowable amount for the contact lenses, scleral, gas permeable (V2531) provided June 
21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related 
group (DRG) code 374. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 374. You say that DRG 374 is 
properly supported by the medical records. The Plan denied your request. The Plan says DRG 374 is not 
supported as the diagnosis of spontaneous bacterial peritonitis. 
 
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 secondary diagnosis code, K65.2, defined as 
Spontaneous bacterial peritonitis. 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 billed with DRG 374. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found there was no specific diagnosis of spontaneous bacterial peritonitis.  
 
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 the inpatient hospital services billed with diagnosis related group (DRG) code 374.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 18 to June 22, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you have never before been charged for the procedures at issue. The Plan denied your request. The Plan says the correct copayment was applied.
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 $300 copayment for each day of days 1 to 5 of each Medicare-covered inpatient hospital stay. You have been asked to pay $1200, or a $300 copayment for each day of a 4-day stay for inpatient hospital
care. 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 on June 18 to June 22, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic exercises (97110 x12), neuromuscular reeducation (97112 x12), therapeutic activities (97530 x12), and self-care/home management training (97535 x12).

You asked the Plan to pre-approve the therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care/home management training. The Plan denied your request. The Plan says these services are not considered reasonable and necessary and are excluded from coverage.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care/home management training. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Our reviewer found that the documentation does not reveal objective findings from the September 13, 2021 physical therapy (PT) evaluation that indicates a need for additional PT. Our physician reviewer also found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

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 therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care/home management training have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic exercises (97110 x12), neuromuscular reeducation (97112 x12), therapeutic activities (97530 x12), and self-care/home management training (97535 x12).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member's health will be jeopardized if he does not got to rehabilitation. The Plan denied your request. The Plan says that the enrollee's medical condition requires further evaluation and treatment in the acute care hospital.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for exacerbation of chronic obstructive pulmonary disease. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services rendered on February 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. Medicare rules say that surgical pathology of any and all submitted 
prostate needle biopsy specimens from a single patient be reported with one unit of service of HCPCS code 
G0416 rather than CPT code 88305. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with code 88305 and not 
the required code, G0416. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology 
services rendered on February 8, 2021.