Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on medical necessity. The Plan denied your request. The Plan says this claim has not been billed in accordance 
with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on 
November 9, 2021. 
 
You asked the Plan to waive the deductible for the specialist visit. You say that you feel there was an error in 
coverage information and you should be reimbursed. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
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 $250 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $250 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the specialist visit was received on 
November 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a specialist 
office visit provided on November 9, 2021.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled 
medications and insulin. The enrollee had stable vital signs, had routine tracheostomy care and used oxygen via 
nasal cannula. The enrollee was at an independent to contact guard assist level for functional mobility including 
gait. She does not require skilled nursing or therapy services on a daily basis. She does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the rituximab injection provided on 
January 14, 2022. 
 
You asked the Plan to waive the coinsurance for the rituximab injection. You say that your rituximab injections 
have always been covered and the broker who signed you up for this plan said they would be covered 100%. 
The Plan denied your request. The Plan says the coinsurance 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 20% co-
insurance for other Medicare-covered Part B drugs.  
 
Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan 
and the member. It is usually called the Evidence of Coverage (EOC) or Member Agreement. We read this 
contract carefully to see what the Plan is supposed to cover. 
 
The Plan sent additional information to us. This information was not received in the original case file from the 
Plan. Our decision was made using all of the information we received.  
You have been asked to pay $1,314.79, which is 20% of the allowed amount for the rituximab injection. The 
allowed amount is $6,573.95 (20% x $6,573.95 = $1,314.79). The rituximab injection falls within the 
Medicare Part B prescription drugs 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 coinsurance for 
the rituximab injection provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on March 22, 2021, through 
March 27, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that Medicare criteria for coverage have 
not been met. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on March 22, 2021, through March 27, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary. The Plan denied your request. The Plan says the enrollee has not completed at least 6 
weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
MRI is not indicated. Our physician reviewer found there needs to be at least 6 weeks of conservative measures 
for low back pain to include physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (43235) provided on 
September 22, 2021. 
 You asked the Plan to pay for the esophagogastroduodenoscopy. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 
43235, 43262 and 43264. 
 
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 43235 is a column II code to column I codes 43262 and 43264; 
however, 43235 was billed with a modifier.  
 
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 esophagogastroduodenoscopy. Our reviewer says that 
CPT code 43235 does not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 
43235 would be inclusive to CPT 43262 and 43264, as, collection of specimen(s)  by brushing or washing, is in 
the description for the base code (43260) group.  In this case, specimen collection by brushing or washing is 
included in CPT 43260(which is the base code for CPT 43262 and 43264).  Procedures described in the base 
code are inherently included in the other services in their base code family. 
 
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 esophagogastroduodenoscopy have not been met. Therefore, we decided 
that the Plan does not have to pay for the esophagogastroduodenoscopy (43235) provided on September 22, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of Age-related osteoporosis without current pathological fracture. The Plan requires a trial of 
zoledronic acid or a history of osteoporosis related fracture before they will approve the requested drug. The 
case file does not contain documentation of an osteoporosis-related fractur, or of trial and failure of zoledronic 
acid. The documentation does not support that zoledronic acid would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 8, 2021, 
through March 13, 2021 and billed with Diagnosis Related Group (DRG) 871. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the DRG 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 DRG 871 with primary diagnosis code A41.9. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services billed with 
DRG 871. Our reviewer says that the documentation submitted does not support the DRG billed. Our physician 
reviewer found sepsis, unspecified organism is not sufficiently supported in the provided documentation as it 
does not describe the patient as meeting sepsis 3 criteria as there was no objective signs of a systemic reaction 
to the pneumonia that led to organ failure and there was no rise in SOFA score.  
 
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 March 8, 2021, through March 13, 2021 and billed with Diagnosis 
Related Group (DRG) 871.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections to be provided at 3 levels. 
 
You asked the Plan to pre-approve facet joint injections to be provided at 3 levels. You say that facet joint 
injection services are medically reasonable and necessary. The Plan denied your request. The Plan says the 
criteria for coverage have not been met for the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that the need for a three or four-level procedure 
bilaterally may be considered under unique circumstances and with sufficient documentation of medical 
necessity on appeal. 
 
We looked at the file and Medicare rules. In this case, the documentation does not provide evidence that there 
is a unique circumstance necessity the three-level procedure. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections to be provided at 3 levels have not been met. Therefore, we 
decided that the Plan does not have to pre-approve facet joint injections to be provided at 3 levels.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from August 6, 2020, through 
August 8, 2020, billed with principal diagnosis code I21.A1. 
 You asked the Plan to pay for the inpatient care as billed. You say that this claim was billed correctly at the 
proper DRG. The Plan denied your request. The Plan says the reported principal diagnosis is not appropriate 
based on the records. 
 
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 I21.A1, defined as 
myocardial infarction type 2. 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 care 
as billed. Our reviewer says that the reported principal diagnosis code is not supported for this admission. Our 
physician reviewer found the patient is a 76-year-old with atrial flutter, presenting with rapid heart rate, fatigue 
and given Lopressor, Cardizem, Lasix, Adenosine, and Esmolol which were ineffective. Cardioversion was 
done which was successful at converting to normal sinus rhythm. 
 
There was insufficient support made in the provided documentation to list myocardial infarction type 2 as the 
principal admitting diagnosis as the atrial flutter was the primary admitting diagnosis which was directly 
treated. There was no noted change in treatment related to the myocardial infarction type 2.   
 
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 care provided from August 6, 2020, through August 8, 2020, billed with principal diagnosis 
code I21.A1.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
close to household distances with a wheeled walker with contact guard to minimum assistance and is contact 
guard assist for transfers. Provided records do not document a significant decline in the enrollees functional 
status to necessitate daily inpatient skilled therapy services. The enrollee does not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the assisted 
living facility with home health care or in a long-term care facility on a part time basis are not appropriate in 
this case. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from September 5, 2021, 
to September 18, 2021, at the Diagnosis Related Group (DRG) billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG billed. You say that this diagnosis is 
supported in the medical record. The Plan denied your request. The Plan says the secondary diagnosis of J96.21 
(acute and chronic respiratory failure with hypoxia) is not supported by the medical record. As a result, a lower 
DRG was paid. 
 
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 a secondary diagnosis of 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 the inpatient 
hospital services at the DRG billed. Our reviewer says that a diagnosis of acute and chronic respiratory failure 
with hypoxia is not supported in the medical record. Our physician reviewer found the patient is a 69 year old 
male who was admitted and treated in the hospital for alcohol dependence with withdrawal presenting with 
altered mental status and hypoglycemia. His oxygen levels were SpO2 83% on room air (baseline 90% room 
air) and placed on 4L of supplemental oxygen via nasal cannula. He was treated with bronchodilators and 
steroids in the emergency room prior to admission. On admission, the patient was stable with normal pulse 
oximetry on the low dose oxygen without accessory muscle use or other signs of acute respiratory distress. 
There was no arterial blood gas results were provided. No respiratory assist support was needed during the 
hospitalization.  
 
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 September 5, 2021, to September 18, 2021, at the Diagnosis 
Related Group (DRG) billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this device is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has a diagnosis of COPD and was admitted with 
pneumonia. PaCO2 was mildly elevated at 47 in hospital. The patient was unable to tolerate bilevel positive 
airway pressure (BiPAP) but improved on oxygen. There is no arterial blood gas test done as an outpatient 
while medically stable, to document chronic CO2 retention. The patient was unable to tolerate BiPAP in hospital, so unlikely patient will tolerate a home ventilator with mask interface. BiPAP with average volume 
pressure assisted support has not been tried and failed. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.