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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 29, 2021, 
to December 3, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were medically necessary and are supported in the record. The Plan denied your request. The Plan says 
the DRG billed is not accurate to the services/care provided. 
 
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 sepsis due to methicillin susceptible staphylococcus 
aureus (A41.01) and severe sepsis without septic shock (R65.20). 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 at the DRG originally billed. Our reviewer says that these 
diagnoses are not supported by the medical records provided. Our physician reviewer found  
 
That the enrollee presented to the hospital with an infected sacral decubitus ulcer. She was noted to have 
normal to low blood pressures with relative hypotension following hemodialysis which did not change during 
her hospital stay through discharge. Vitals were otherwise stable including oxygenation. Organ function was 
normal and stable with normal platelets and baseline and predictable fluctuations in creatinine due to the 
enrollees end stage renal disease (ESRD). Mental status did not change beyond her baseline during the 
hospital stay according to the notes. There was no significant evidence of the enrollee experiencing a 
dysregulated systemic host response the infection to meet Sepsis 3 criteria. The diagnoses of sepsis due to 
methicillin susceptible staphylococcus aureus (A41.01) and severe sepsis without septic shock (R65.20) are 
therefore, not sufficiently supported in the medical records.  
 
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 on November 29, 2021, to December 3, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study provided on November 1, 2021.
You asked the Plan to waive the copayment for the sleep study. You say that there was no doctor visit on this
day. The Plan denied your request. The Plan says this cost sharing was charged 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 $175
copayment for Medicare-covered outpatient diagnostic procedure and test in an outpatient facility.
You have been asked to pay a $175 copayment for the sleep study. The Plan provided documentation
confirming you received a sleep study on this date of service. This item/service falls within the Medicare covered
outpatient diagnostic procedure and test in an outpatient facility 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 sleep study provided on November 1, 2021.
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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require the intensity of rehabilitation physician oversight provided in the acute inpatient 
rehabilitation setting. The enrollee does not require rehabilitation nursing for complex wound care, parenteral 
nutrition or tube feedings, tracheostomy management or bowel and bladder management. His medical and 
rehabilitation needs do not require the intensive interdisciplinary approach provided in acute inpatient 
rehabilitation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 64483. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64483 billed for date of service March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
October 20, 2021. 
 
You asked the Plan to pay for the psychiatric service. You say that your primary doctor felt you needed this 
service due to issues with your memory and confusion. You say that you were told this doctor was in-network. 
You also say that this test was necessary to figure out what was wrong with you. The Plan denied your request. 
The Plan says the provider in this case is not contracted with Medicare and therefore is eligible to receive 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychiatric service have not been met. This provider is not eligible for Medicare payment. 
Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) 
provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level (code 22869), the Vertiflex Superion. 
 
You asked the Plan to pre-approve the Vertiflex Superion. You say that the Vertiflex Superion is medically 
necessary. The Plan denied your request. The Plan says the Vertiflex Superion is 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 pre-approve the Vertiflex Superion. Our reviewer 
says that the requested Vertiflex Superion is not considered medically reasonable and necessary. Our physician 
reviewer found that the interspinous process distraction devices remain experimental. More research is needed. 
 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 Vertiflex Superion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar, single level 
(code 22869), the Vertiflex Superion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for Marfan Syndrome. 
 
You asked the Plan to pre-approve genetic testing. You say that this test is not medically necessary as it is not 
clear how this will impact the enrollee's treatment. The Plan denied your request. The Plan says this test is 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that it is not clear how the test result would have any influence on the enrollees treatment. 
There is no evidence to support its role in this enrollees clinical management. In summary, the requested 
testing is not considered reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing for Marfan Syndrome.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are weak in your legs and need to build up 
strength. The Plan denied your request. The Plan says the records provided do not support the need for SNF 
care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs.  The enrollee is ambulating household distances.  The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GeneSight pharmacogenomic (PGx) testing (81479). 
 
You asked the Plan to pre-approve GeneSight testing. You say that this test is medically necessary as the 
enrollee has tried several antidepressants which were ineffective and caused significant side effects. The Plan 
denied your request. The Plan says the requested test is not medically necessary under Medicare guidelines. 
 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 GeneSight testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the records provided indicate that the enrollee has a diagnosis of Major 
Depressive Disorder Recurrent (F33.0), Generalized Anxiety Disorder (F41.1) and Posttraumatic Stress 
Disorder (F43.2), which are conditions that do not meet the Medicare coverage criteria for the GeneSight 
Psychotropic Assay/Unlisted Molecular Pathology Procedure. This enrollees symptoms have not been severe 
enough to require this procedure, and this test is not considered medically necessary and reasonable in the 
treatment of this individual. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve GeneSight pharmacogenomic (PGx) testing (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench for tub or toilet. 
 
You asked the Plan to pre-approve a transfer bench. You say that this equipment is necessary for your 
condition. The Plan denied your request. The Plan says this item does not meet the definition of DME and is 
not covered by Medicare or the Plan. 
 
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 a transfer bench for tub or toilet.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical spine 
(72040), and the x-ray exam of the lumbar spine (72100) rendered by the out-of-network (OON) provider on 
October 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
 
 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. Additionally, the rules say that the only chiropractic service 
Medicare covers is manual manipulation of the spine to correct a subluxation. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Additionally, the Plans contract  
says that the only covered chiropractic service is manual manipulation of the spine to correct a subluxation. 
Therefore, we decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical 
spine (72040), and the x-ray exam of the lumbar spine (72100) rendered by the out-of-network (OON) provider 
on October 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 27, 2022, 
through June 24, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says due to the RAP claim being received more than thirty (30) days from the State of 
Care (SOC) no payment will be issued for home health care services due to late RAP penalty. 
 
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 home health services have not been met. The deadline for 
submission of the home health claims Notice of Admission (NOA) was within five (5) days of the start of care. 
The provider submitted the NOA on July 1, 2022, for the home health care period which started on May 27, 
2022. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
May 27, 2022, through June 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron. 
 
You asked the Plan to pre-approve ondansetron. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ondansetron.  
 Benefits for ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 28, 2022, to 
March 30, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 at the DRG originally billed. Our reviewer says that the documentation does not support the DRG 
billed. Our physician reviewer found the enrollee was admitted for sepsis secondary to urinary tract infection 
status post a mechanical fall at home. The enrollee was discharged to a skilled nursing facility in stable 
condition. There was no clinical or laboratory evidence of sepsis. DRG-871 was not supported by the 
documentation. The principal diagnosis A419 Sepsis, unspecified organism was not supported by the 
documentation.  
 
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 from March 28, 2022, to March 30, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (21 hours per week). 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says there will be a reduction in hours to 14.75 hours per week from the 
requested 21 hours per week. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional hours. Our reviewer says 
that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found 
that there are no documented skilled nursing or skilled therapy needs. There is no evidence that additional 
hours are required to assist in the treatment of an acute illness or injury. As such, the requested additional hours 
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 additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home health aide (21 hours per week).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of EBV-
positive lymphoproliferative disorder secondary to immune dysregulation medication for the treatment of 
psoriasis. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the 
enrollee's condition. Medicare-approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The services are therefore not reasonable and medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Truxima.