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

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 16, 2021, to 
March 24, 2021, as billed with Diagnosis Related Group (DRG) 853. 
 
You asked the Plan to pay for inpatient care billed with DRG 853. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 853 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 982 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care billed with DRG 853. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee presented to the facility with 
complaints of the absence of urination for several days, pus coming out of his penis, constant pelvic pain, lower 
abdominal pain, and diarrhea. The enrollee had a past medical history of prostate cancer, hyperlipidemia, 
seizures, chronic infective cystitis, gastroesophageal reflux disease, and hypertension. A computed tomography 
scan of the abdomen and pelvis was obtained, and findings were concerning for an abscess. On March 19th, the 
enrollee was taken to the operating room for flexible cystoscopy, retrograde urethrogram, irrigation and 
aspiration of pelvic fluid. The enrollees admitting diagnoses included bladder disruption/disconnection from 
urethra, a pelvic abscess, and urinary tract infection. Additional treatment included intravenous antibiotics and 
Infectious Disease consultation. In the emergency room, the enrollee was noted to be alert and oriented x3 with 
a Glasgow Coma Scale (GCS) of 15. Vital signs showed a temperature of 98.3, pulse of 130, respiratory rate of 
15, blood pressure of 109/73, and a SpO2 of 100%. While review of the laboratory data also revealed a slightly 
elevated white blood cell count (WBC) at 10.3, there was no clinical or laboratory evidence of sepsis. The 
review has determined that the medical records did not support the billing of sepsis, unspecified organism 
(A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 853 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from March 16, 2021, to March 24, 2021, 
as billed with Diagnosis Related Group (DRG) 853.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from February 4, 2019, to 
February 5, 2019, as billed with diagnosis related group (DRG) 073. 
 
You asked the Plan to pay for inpatient care billed with DRG 073. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 073 is not 
appropriate as the diagnosis of acute kidney failure with tubular necrosis (N17.0) is not supported in the 
medical record. The Plan argues that DRG 074 is more appropriate in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care billed with DRG 073. Our 
reviewer says that the diagnosis of acute kidney failure with tubular necrosis (N17.0) is not supported in the 
medical record for this inpatient admission. Our physician reviewer found that the enrollee was brought to the 
emergency department on February 4, 2019, due to a near syncopal episode, no witnessed Seizures. The 
enrollee was at an adult daycare center. He was hypotensive 85/49, given fluids, and his blood pressure 
improved to 119/60. He was treated with IV fluids and admitted. On February 5, 2019, the progress note 
indicated that his blood pressure was 135/70 and documents acute chronic kidney disease. A face sheet from 
outside facility documented history of diabetes mellitus with other diabetic kidney complication. The discharge 
summary documented renal insufficiency and acute on chronic kidney disease 3. The review indicates that the 
medical records do not support the billing of acute kidney failure with tubular necrosis (N17.0). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 073 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from February 4, 2019, to February 5, 
2019, as billed with diagnosis related group (DRG) 073.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
23, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you thought you only had a 
$125 copayment as that is what the office said, not a $225 copayment. The Plan denied your request. The Plan 
says the copayment applied was 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 $225 
copayment for outpatient hospital services.  
 
You have been asked to pay a $225 copayment for an outpatient surgery. An outpatient surgery falls within the 
Outpatient Surgery or Procedure 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 
an outpatient surgery provided on March 23, 2022.  
 Your complaint about the office giving you an incorrect copayment amount is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for photochemotherapy provided on February 
1, 2022, to February 17, 2022. 
 
You asked the Plan to waive the copayments for a Procedure. You say that you cannot afford the copayments 
for each of these procedures. The Plan denied your request. The Plan says the copayment applied was 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 $265 
copayment for in-network covered services at an outpatient hospital.  
 
You have been asked to pay $52.92, which is less than the standard $260 copayment for each visit. There were 
4 visits, resulting in a total cost of $211.68. Photochemotherapy billed by the hospital falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 copayments for photochemotherapy provided on February 1, 
2022, to February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64484) provided on August 27, 2021. 
 
You asked the Plan to pay for code 64484. The Plan denied your request. The Plan says payment for code 
64484 is bundled into payment for code 27096. 
 
 
 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 64484 
is a column II code to column I code 27096. 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 services (64484) provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with septic shock. There is a diagnosis of COPD, but full pulmonary function testing results are not provided, 
except there is no obstruction but RV is increased. RV/TLC is not mentioned. There is severe obesity, BMI 53, 
and a diagnosis of OHS.  On admission, venous blood gases suggested hyperventilation, with low PvCO2. It is 
possible that the enrollee has chronic CO2 retention related to OHS, but sepsis drove hyperventilation at the 
time of admission. She has home bipap, but no compliance data are provided. There is no evidence of bipap 
failure according to Medicare criteria. The AVAPS mode can be provided via bipap, and this has apparently 
not been tried at home.  Medicare does not cover a home ventilator when used as bipap. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62321). 
 
You asked the Plan to pre-approve the injections. You say that the service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using same scale for at least three months.  
 
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 injections are not medically necessary. Our physician reviewer found the enrollee underwent the last C6-C7 
injection on April 18, 2022. This previous injection provided 80% pain relief but for less than one month. The 
enrollee did not have at least three months of at least 50% sustained improvement in pain relief. 
 
 
 
 
 
 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 (62321).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric emptying study (78264). 
 
You asked the Plan to pre-approve a gastric emptying study. You say that the requested testing is medically 
necessary. The Plan denied your request. The Plan says the requested testing does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a gastric emptying study. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had constipation for a couple of days, followed by loose stool. The 
cramps improved after bowel movement. The enrollee also reported mild acid reflux, 1-2 times, which 
responded to medications as needed. The abdominal examination and laboratory studies were unremarkable. 
The enrollee did not have a history of diabetes, and did not report unexplained nausea, vomiting, weight loss, 
upper abdominal discomfort, bloating, or early satiety. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a gastric emptying study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a gastric emptying study (78264).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on October 22, 2021. 
 
You asked the Plan to waive the copayment for an eye exam. You say that there should not be a copayment for 
this exam, as it is a diabetic screening. The Plan denied your request. The Plan says the copayment applied was 
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 $40 
copayment for per visit for exams of the related to a medical condition. 
 
 
  You have been asked to pay a $40 copayment for an eye exam. An eye exam falls within the Vision Care 
benefit category. The records show a medical eye exam was performed. 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 an eye exam provided on October 22, 2021. 
 
Your complaint about your provider giving you additional medical services without permission, is related to an 
eye hemorrhage, which made this an exam related to a medical condition and is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits (97110). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 
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 additional PT visits. 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 a physical therapy note dated 5/24/2022 indicated that the enrollee 
continued to be minimum assistance with negotiating stairs. His lower extremity strength continued to be 3/5 
bilaterally. As with all physical therapy, however, there must be documentation indicating progress with 
continued therapy in terms of improvement with range of motion, motor strength, and function. The enrollee 
has been receiving ongoing physical therapy since August of 2020. His level of mobility and motor strength 
have remained the same. At this point, continued therapy would be considered maintenance in nature and does 
not require the skilled therapy services of a physical therapist. He can continue with an independent home 
exercise program. Alternatively, other assistive devices can be considered to mitigate the enrollee's risk for fall 
as well as improving functional mobility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eight (8) additional physical therapy (PT) visits (97110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided in Indonesia on March 1, 2021 to 
March 5, 2021. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records show the enrollee has resided outside the United States 
since 2020. The service was not 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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for surgical services provided in Indonesia on March 1, 2021 to March 5, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99203) provided on February 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" is interpreted to mean a 
patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., 
surgical procedure) from the physician or physician group practice (same physician specialty) within the 
previous 3 years. 
 
We looked at the file and Medicare rules. The requested evaluation and management service was billed as a 
new patient visit. However, a visit was provided by the same provider on December 23, 2021. Since this visit 
was provided within 3 years of the previous visit, this service is not payable as a new patient visit. 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 (99203) provided on February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch brand diabetic test strips. 
 You asked the Plan to pre-approve the OneTouch brand diabetic test strips. You say that the Contour brand test 
strips are inaccurate and you have used OneTouch brand for years. The Plan denied your request. The Plan says 
the requested brand of test supplies is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The record shows that the enrollee trialed Contour brand test strips, 
however the record does not show a trial of any other plan preferred brand test strips. This includes FreeStyle, 
FreeStyle Lite, FreeStyle InsuLinx, FreeStyle Precision Neo, and Precision Xtra. Based on this information, we 
decided that Medicare rules for coverage of the OneTouch brand diabetic test strips have not been met. 
Therefore, we decided that the Plan does not have to pre-approve OneTouch brand diabetic test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466x12). 
 
You asked the Plan to pre-approve a non-invasive home ventilator. You say that the requested ventilator is 
medically necessary. The Plan denied your request. The Plan says the requested ventilator does not meet 
criteria 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a non-invasive home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the rules also say that 
the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of 
each persons medical condition. There must be enough detailed information in the medical record to justify the 
treatment selected. The record indicates that you have obstructive sleep apnea and do not qualify for home 
oxygen by a six-minute walk test. The record provided is insufficient to establish the medical necessity of the 
requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a non-invasive home ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a non-invasive home ventilator (E0466x12).