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 September 4, 2021, to 
September 10, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not supported as the diagnoses of sepsis due to streptococcus pneumoniae (A40.3) and severe sepsis without septic 
shock (R65.20) are not supported in the medical record. The Plan argues that DRG 193 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 871. Our 
reviewer says that the diagnoses of sepsis due to streptococcus pneumoniae (A40.3) and severe sepsis without 
septic shock (R65.20) are not supported for this inpatient admission. Our physician reviewer found the 
information in the received documentation is inconsistent/unclear regarding a diagnosis of sepsis. Even though 
severe sepsis is documented, supporting medical records are not found within the record. There is no evidence 
of significant physiologic instability as evidenced by an increase of 2 or more points in the Sequential Organ 
Failure Assessment (SOFA) score, after fluid resuscitation, that were not easily explained by causes other than 
sepsis in this enrollee with pneumonia, congestive heart failure, and with "thrombocytopenia secondary to his 
alcohol abuse". As noted above, although the provider documented severe sepsis, reasonable support within the 
health record must be present to support the diagnosis. 
 
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 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from September 4, 2021, to September 
10, 2021, as billed with Diagnosis Related Group (DRG) 871.
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 the enrollee meets the full criteria for an IRF stay. 
You say that a lower level of care in a skilled nursing facility cannot provide the total interdisciplinary 
approach needed and would keep the enrollee away from her home and family for a longer amount of time. The 
Plan denied your request. The Plan says the enrollee does not need an intensive team for rehabilitation needs 
and discharge planning. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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 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 
was admitted for confusion and a urinary tract infection. The enrollee's medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by an 
out-of-network (OON) provider on January 4, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by an out-of-network (OON) 
provider on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on December 14, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the physician services. You say that the facility only allows certain providers into 
the facility and the service provided was based on an urgent need. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent in nature. 
 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 the physician services provided on December 14, 
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 9, 2021. 
 
You asked the Plan to pay for lab tests. You say that lab work is necessary to ensure that the enrollee is 
assessed for proper treatment. The Plan denied your request. The Plan says the denial of payment for this 
testing is correct, because the record does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 11 is used to describe samples taken in an office setting. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lab tests have not been met. Specifically, this claim was billed with the office POS code. The 
records show that the sample for this testing was taken in an assisted living facility (ALF) setting; therefore, the 
office POS code is not appropriate for this claim. Therefore, we decided that the Plan does not have to pay for 
laboratory testing provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00190 and 99140) provided on 
November 24, 2021. 
 
You asked the Plan to pay for the anesthesia services (00190 and 99140). You say that charges are separately 
payable and not bundled with any other services. You say that anesthesia charges are reimbursed separately and 
the claim should be reprocessed for payment. The Plan denied your request. The Plan says the claim was billed 
with an inappropriate place of service 22 (outpatient). 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered 
inpatient, shall, at a minimum, report the inpatient hospital POS code 21 
 
We find that CPT code 00190 and 99140 are not supported in the medical record. Specifically, POS 22 (on-
campus outpatient hospital) was billed, but the records show the enrollee was an inpatient at the time the 
services were received. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services (00190 and 99140) have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services (00190 and 99140) provided on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dynamic adjustable knee extension / flexion device 
(E1810) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a dynamic adjustable knee extension / flexion device. You say that this 
equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says there are in-
network providers available to provide the equipment. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a dynamic adjustable knee extension / flexion device (E1810) to be provided by an out-of-network (OON) 
provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services (A0429, A0425) provided on 
August 26, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were billed appropriately and 
were medically necessary. The Plan denied your request. The Plan says that the diagnosis billed with this claim 
is not valid with the provided services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not forward a copy of the original claim submitted so 
that we could verify what was billed. In addition, there is no Medicare rule regulating what diagnosis codes are 
appropriate to bill on ambulance claims for the state where these services took place. Therefore, we decided 
that the Plan has to pay for the ambulance transportation services (A0429, A0425) provided on August 26, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on April 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is a non-network provider who does not work with the 
member's health plan, and the member was referred by a provider who also does not work with the member's 
plan. The Plan also says that the member's primary physician did not refer the services. 
 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 pathology services provided on April 7, 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 laboratory services rendered on June 1, 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 covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 12, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. 
  Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 12, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the power wheelchair purchased on 
August 9, 2021. 
 
You asked the Plan to provide reimbursement for the power wheelchair. You say that the enrollee truly requires 
this power wheelchair, and other options are not able to help him within the home. The Plan denied your 
request. The Plan says there was no face-to-face evaluation or standard written order from a treating physician. 
There is also insufficient evidence to show that the enrollee requires this equipment for use in the home. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for power wheelchairs that are filed 
without a face-to-face evaluation and SWO are denied as statutorily noncovered. 
 
We looked at the file and Medicare rules. The physician was not seen face-to-face until after the power 
wheelchair was purchased and no SWO was submitted. In addition, records from a home evaluation were not 
submitted for review. Based on this information, we decided that Medicare rules for coverage of the power 
wheelchair have not been met. Therefore, we decided that the Plan does not have to provide reimbursement for 
the power wheelchair purchased on August 9, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Retacrit. 
 
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 that 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 medically necessary. Our physician reviewer found the enrollee has a diagnosis of anemia on 
chronic kidney disease, stage III, in the setting of chemotherapy for prostate cancer. Recent hemoglobin was 
less than 10 g/dl. The Food and Drug Administration (FDA) has stated that the requested drug is indicated for 
the enrollee's condition. The Retacrit is reasonable and medically necessary and safe and effective at this time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Retacrit.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit nail debridement and 
provided on January 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit nail debridement. You say that the assisted living 
facility is responsible to obtain prior authorization for all of their patients, which should also cover for the 
medical treatments provided by the doctor. The Plan denied your request. The Plan says upon review, an 
authorization was not obtained prior to the services being rendered and the provider is not participating with the 
Plan. 
 
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 domiciliary or rest home visit nail debridement 
and provided on January 26, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided support 
the need for an inpatient hospital admission. The Plan denied your request. The Plan says inpatient hospital 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are 
met in this case. Our physician reviewer found the enrollee presented to the emergency department on May 16, 2022, after she was urged by her social worker. Her social worker went to check on her at home and found that 
she was living at home without power. The enrollee has difficulty taking care of herself independently 
secondary to her Parkinson's disease. The records provided do not support that, at the time of the request for an 
inpatient admission, the requesting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier emergency department 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 the inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee's needs can be met at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until a lower level of 
care is more appropriate. The enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Completion of care at the current facility is recommended. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.