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

 
We decided that the Plan has to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that that your care could be provided as an observation 
or short stay. 
 
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 pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are medically reasonable and necessary. You were admitted with 
complaints of chest pain. Evaluation revealed new EKG changes, a blood pressure of 179/102, elevated 
troponin, and volume overload requiring hemodialysis. You were admitted for further testing and consultation 
with cardiology. The record shows that at the time of inpatient admission the admitting physician reasonably 
expected that your necessary hospital care would span two midnights, and medically necessary care did span a 
time period of more than 2 midnights. Our physician reviewer found that your condition meets criteria for 
coverage of inpatient hospital services.  
 
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 hospital services have been met. Therefore, we decided that the Plan 
has to pre-approve inpatient hospital services.  
 
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 pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (CPT code 99291) provided on August 15, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says it was included to the global period of the minor surgical procedures performed by a provider of 
the same specialty. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. CPT code 99291 is included in the 
global period of codes 31624 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage), 36556 (Insertion of non-tunneled centrally inserted central venous 
catheter; age 5 years or older),36620 (Arterial catheterization or cannulation for sampling, monitoring or 
transfusion (separate procedure); percutaneous) billed on the same date of service. Both the providers have the 
same specialty Internal medicine  Pulmonary disease and both the claims were billed by same billing group. 
An appropriate modifier was not billed on the claim to indicate the code 99291 as not included to the global 
period of the minor surgical procedures. Therefore, we decided that the Plan does not have to pay for critical 
care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 
99291) provided on August 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code G0482) provided on July 
13, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code G0482 90 (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory service (CPT code G0482) provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 87150) provided on 
January 8, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 87150 (11 
Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on January 8, 2021, and received by the lab on January 11, 2021; therefore, the billed 
code cannot be verified. It is noted multiple attempts were made to obtain additional information from the 
provider. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 87150) 
provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 0089U) provided on June 
3, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says your request does not meet Medicare rules as the size of the skin lesion was not 
defined in the medical records provided. 
 
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 laboratory service. Our physician 
reviewer found the dimension of the lesion needs to be between 5mm and 19 mm according to LCD criteria, 
however, there was no provided dimensions found in the provided documentation to determine if the size meets 
requirements. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (CPT code 0089U) provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hyaluronan or derivative, synvisc or synvisc-one, for 
intra-articular injection, 1MG (CPT code J7325) provided on January 6, 2021. 
 
You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the safety and efficacy of hylan G-F 20 has not been established in locations other 
than the knee, for conditions other than osteoarthritis, or for concomitant use with other intra-articular 
injectables. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the safety and efficacy of hylan G-F 20 has not been established in 
locations other than the knee, for conditions other than osteoarthritis, or for concomitant use with other intra-
articular injectables. The review has determined that the items/services at issue in this case are 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1MG (CPT 
code J7325) provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncology (prostate), promoter methylation profiling by real-
time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm 
reported as a likelihood of prostate cancer detection on repeat biopsy (81551) provided on September 24, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that ConfirmMDX is a covered benefit under 
Original Medicare Part B. Medicare requires Medicare Advantage Organizations to reimburse non-contracted 
providers no less than the amount that would be paid under Original Medicare. The Plan denied your request.  The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 Oncology (prostate), promoter methylation 
profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded 
tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy (81551) provided on 
September 24, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 25, 2020, through 
July 7, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the Infectious Disease consultant assessed 
the member with sepsis and documented it clearly and consistently in the consultation note and progress notes. You state a systemic reaction to infection was evident in this member on admission and more resources were 
used in view of close monitoring, evaluation with serial investigations, consultation and treating with 
intravenous (IV) antibiotics and IV fluids, hence, sepsis, unspecified organism was appropriately coded as the 
principal diagnosis. The Plan denied your request. The Plan says sepsis DRG is not supported, DRG 239 was 
paid and is upheld. 
 
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 239. 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 hospital care. Our physician reviewer found the review has determined 
that the documentation not support the Sepsis DRG billed, Lactic acid 1.7, CR 1.6 T97, P 100 97% RA, Procal 
.52 PLT 336 , WBC 17.9positive wound culture, negative blood culture. Sepsis criteria was not met.  Sepsis 
DRG was not supported, DRG 239 was paid and is upheld.  
 
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 care provided from June 25, 2020, through July 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) visits (97039) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT visits. You say that you changed plans in December, and you had no 
idea that by changing plans, you would need a prior authorization for services. You also say you need to 
continue treatment and you would like to continue with the same provider that you began PT with. The Plan 
denied your request. The Plan says services should be received from network providers who are listed in the 
provider directory. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) visits (97039) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 28, 
2020 to September 2, 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 the submitted records do not support the billing of diagnosis code J96.21. 
 
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 J96.21 (acute and chronic 
respiratory failure with hypoxia). 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 these services. 
Our reviewer says that the submitted records do not support the billing of diagnosis code J96.21. Our physician 
reviewer found the enrollee presented with chest pain and dyspnea. A chest x-ray revealed emphysematous 
changes without infiltrates or edema. Computed tomography (CT) angiogram of the thorax revealed 
hyperexpanded lungs with emphysematous changes. He was admitted for further evaluation and management 
of chronic obstructive pulmonary disease (COPD) exacerbation. He was ultimately discharged to home on 
September 2, 2020 with continued use of baseline nasal oxygen. The records do not support the billing of 
diagnosis J96.21.  
 
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 rendered from August 28, 2020 to September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code 
70544) provided on December 18, 2021. 
 
You asked the Plan to pay for the MRA. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 
is a column II code to column I code 70551. 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 MRA, head; without contrast material(s) (CPT code 70544) 
provided on December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CP) code(s): 82728, 83540, 83550) 
provided on October 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The AY modifier is used 
when the lab services are not related to ESRD. The provider reported routine lab services related to the 
treatment of ESRD, which does not follow industry standard coding rules. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CP) code(s): 82728, 83540, 83550) provided on October 13, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed wing air mileage, per statute mile (A0435) provided 
on September 21, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the enrollee's plan should have paid for 
the 1154 miles that were billed. You say that the claim was split based on dollar amount and units. You say that 
the enrollee was transported back to the United States for medically necessary services. The Plan denied your 
request. The Plan says the air ambulance services were not medically necessary.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the ernollee suffered from an illness or injury that 
contraindicated transportation by any means other than ambulance. At the time of transfer the enrollees 
condition was stabilized and did not require emergency ambulance transport. The reviewer found that in the 
medical records provided there is no clear documentation that the transferring hospital did not have adequate 
facilities to provide the medical services needed by the patient. Records report the originating hospital did not 
have platelets to transfuse the enrollee, yet records report she was given a platelet transfusion at the hospital to 
increase her platelet count from 5000 to 14,000. Therefore, the reviewer found that the air ambulance services 
were 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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the fixed wing air mileage, per statute mile (A0435) provided on September 21, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 26, 2021. 
 
You asked the Plan to pay for these services. You say that the records do not document the results of a drug 
screen were presumptively positive or results of the screen were negative, and this negative finding was 
inconsistent with the enrollee's medical history or no presumptive test was available, locally and/or 
commercially, as may be the case for certain synthetic or semi-synthetic opioids. The testing does not meet the 
criteria for coverage and was not medically necessary. The Plan denied your request. The Plan says the services 
were not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that drug testing is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that you 
disagree with the denial. Our physician reviewer found the services were not 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 pay for the drug testing rendered on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left-sided destruction by neurolytic agent. 
 
You asked the Plan to pre-approve left-sided destruction by neurolytic agent. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary when specific criteria are met.  
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 left-sided destruction by neurolytic 
agent. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
request for left radiofrequency ablation is not supported by the records submitted. At this time, the request is 
deemed 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 left-sided destruction by neurolytic agent have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left-sided destruction by neurolytic agent.