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 from March 10, 2022, to 
March 11, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the entire stay was medically 
necessary and should be paid. The Plan denied your request. The Plan says the patient was admitted to the 
hospital from February 19, 2022, to March 11, 2022. The Plan has paid for the hospitalization from February 
19, 2022, to March 9, 2022, but is denying payment for the last two days of the stay. The Plan contends that 
these two days were not medically necessary. The patient's central venous catheter could have been removed on 
March 10, 2022, with the member being discharged on that date. 
 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 inpatient hospital services. Our reviewer 
says that the inpatient services provided from March 10, 2022, to March 11, 2022, are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the member was admitted to the hospital 
on February 19, 2022, with confusion. He was found to have hydrocephalus and meningitis. He did not have 
fever, low blood pressures, seizures or evidence of new or ongoing infection on the dates in question. The 
member had a stent placed in the brain on March 9, 2022, without complication. IV antibiotics were completed 
on March 10, 2022. The central venous catheter could have been removed on March 10, 2022 with member 
being discharged on that date. The last two days of this inpatient hospitalization were not medically reasonable 
or necessary. The patient could have been safely discharged on March 10, 2022. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided from March 10, 2022, to March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from February 2, 2021, to 
February 5, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not 
supported. 
 
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 diagnosis codes A41.9, I21.4, and N17.0. We asked 
our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the services. Our reviewer says that the billed diagnosis 
codes are not supported by the records provided. Our physician reviewer found that the enrollee had pain on the 
left side, fever, difficulty breathing, pneumonia, a chronically inflamed gall bladder, a problem with renal 
function and some abnormal blood tests related to the liver and heart. There was no documentation in the 
medical record by the clinician that there is life-threatening, acute organ dysfunction or failure due to a 
dysregulated response to the infection, as the current definition states from Sepsis-3 guidelines (for example, 
acute kidney failure due to sepsis). For Acute kidney failure with tubular necrosis, there was very little 
response of the creatinine level to IV fluids during the inpatient stay. The records do state that the enrollee had 
chronic kidney disease, stage 3. A baseline creatinine level was not found in the records. The creatinine stayed 
around the same level in the hospital and did not meet nationally set criteria (KDIGO) for acute kidney 
injury/failure. The review has determined that the billed DRG 871 was not supported by the records provided 
in this case.  
 
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 services provided from February 2, 2021, to February 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on May 11, 2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you disagree with the copayment 
applied for scan. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay a $75 copayment for a duplex scan. A duplex scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a duplex scan provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography scan (CT scan) of the head or brain 
provided on June 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a CT scan of the head or brain. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services were rendered and referred by non-
participating providers. The Plan also says that the services were not approved in advance. 
 
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 computed tomography scan (CT scan) of the 
head or brain provided on June 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 13, 2021 billed with 
codes 81230, 81241, 81249, 81291, 81335, and 81406. 
 
You asked the Plan to pay for the genetic testing 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 13, 2021 billed with codes 81230, 81241, 81249, 81291, 81335, and 81406.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for telehealth visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 telehealth visit provided on April 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services coded 88341, 88342, 88360, and 88381 
provided on December 20, 2021. 
 
You asked the Plan to pay for laboratory services. 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 services with the appropriate CPT code. 
 
We find that CPT codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
these codes have a physician Fee Schedule professional component/technical component indicator of 1. The 
claim was billed with a place of service of 22, Outpatient Hospital. The professional interpretation was 
furnished in the same payment locality from where the technical component was furnished. We find that the 
Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting physician. This means the services rendered 
were billed incorrectly. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
coded 88341, 88342, 88360, and 88381 provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on August 13, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you have never needed a referral and it 
was an annual physical. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 
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 specialist office visit provided on August 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing services provided on April 4, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says procedures should be reported with the most 
comprehensive code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing services provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the medical records prove the services were 
medically necessary. The Plan denied your request. The Plan says the testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We looked at the file, and Medicare rules. Testing billed with code 81455 is unlikely to impact therapeutic 
decision making. 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 lab testing 
services provided on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 11, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this service is not 
covered when obtained from a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on March 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (37232) provided November 19, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed code. 
 
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 37232 is Revascularization, endovascular, open or 
percutaneous, tibial/peroneal artery, unilateral. 
 
 
 
 We find that CPT code 37232 is not supported in the medical record. Specifically, the provided did not 
document the additional branch where the procedure was done. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (37232) provided November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 29, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 laboratory services 
rendered on December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81001) provided on July 1, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 81001 is "Urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, with microscopy". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 81001 is 
not supported by the records provided. Our reviewer found that the medical record does not include 
documentation of a laboratory report to confirm this service was performed. The medical record includes an 
evaluation and management service, which does not include laboratory services. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (81001) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483, 64484). 
 
You asked the Plan to pre-approve the injections. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that that epidural steroid injection (ESI) will be 
considered medically reasonable and necessary when the criteria have been 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 the injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
does not indicate the enrollee was experiencing radicular symptoms and signs. Therefore, the reviewer found 
that the requested injections 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections (64483, 64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory services provided on April 26, 
2022 and May 24, 2022 by an OON provider. 
 
You asked the Plan to pay for an office visit and laboratory services. You say that the enrollee was seen by the 
physician and not a nurse practitioner. 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 an office visit and laboratory services provided on 
April 26, 2022 and May 24, 2022 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for x-rays on October 03, 2021. 
 
You asked the Plan to waive the deductible for x-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 there is a $500 deductible which applies to Outpatient basic radiological 
services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
basic radiological services. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $500 deductible which applies to Outpatient basic radiological services. This cost sharing is a contractual 
obligation that had not been met at the time x-ray was received on October 3, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for x-rays on October 03, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right femoral/popliteal revascularization. 
 
You asked the Plan to pre-approve right femoral/popliteal revascularization. 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 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 right femoral/popliteal 
revascularization. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not support the medical 
necessity of the procedures in question. The most recent visit documents the enrollee has an ulcer on the left 
lower extremity and pain following revascularization of the left lower extremity. There is no documentation 
that the enrollee is having symptoms or tissue loss on the right. There are areas in the note where leg pain is 
specifically addressed and is limited to the left side. It is documented that he ambulates without difficulty. It is 
documented that he has pedal Doppler pulses present bilaterally. Aankle brachial index (Abi) 1.17 on right. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right femoral/popliteal revascularization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve right femoral/popliteal revascularization.