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

We decided that the Plan does not have to waive the deductible for a cardiovascular stress test provided on  
June 18, 2021. 
 
You asked the Plan to waive the deductible for a cardiovascular stress test. You say that this service has been 
covered on a previous date of service. The Plan denied your request. The Plan says cost sharing is a contractual 
obligation under the plan and cannot be waived. 
 
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 your combined in-network and out-of-network deductible is $500. This is the 
amount you have to pay out-of-pocket before we will pay our share for your covered medical services, which 
applies to physician's services for a cardiovascular stress test. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category of 
physician's services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible for covered medical services.  
 
This cost sharing is a contractual obligation that had not been met at the time a cardiovascular stress test was 
received on June 18, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
physician's services for a cardiovascular stress test provided on  
June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from September 12, 
2019 to September 15, 2019. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of DRG 061 with secondary diagnosis code N17.0. The Plan denied your request. The Plan says the 
medical records do not support the billing of DRG 061 with secondary diagnosis code N17.0. 
 
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 061 with secondary diagnosis code N17.0: 
Acute kidney failure with tubular necrosis. 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 medical records do not support the billing of DRG 061 
with secondary diagnosis code N17.0. Our physician reviewer found the enrollee presented with slurred speech 
and was diagnosed with a cerebral vascular accident. A urinalysis was obtained and showed no evidence of 
characteristic urinary sediment. In addition, the fractional excretion of sodium could not be established based 
on labs available for review. If neither of these diagnostic indicators are present, a combination of other less 
specific parameters are considered such as response to fluid repletion, blood urea nitrogen (BUN)/serum 
creatinine ratio, urine osmolality, and spot urine sodium level. Considering all these factors, there was still 
insufficient objective clinical evidence to validate the diagnosis of acute tubular necrosis. While it was noted 
the enrollee had evidence of a BUN/Creatinine ratio less than 20, this alone is not enough to validate the 
diagnosis. On admission, the enrollee's creatinine was 1.5 and the GFR was 34. Treatment with intravenous 
fluids was initiated, and within 48 hours, the creatinine improved to 1.1 which was within the facility's normal 
reference range. There was no urine osmolality, spot urine sodium level, or evidence of hypoperfusion. The 
review has determined that the medical records did not support the billing of DRG 061 with secondary 
diagnosis code N17.0: Acute kidney failure with tubular necrosis.  
 
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 hospital services provided from September 12, 2019 to September 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were 
not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the lab services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 18, 2021, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutment (D6056), implant supported 
crown (D6065), and unspecified preventive service (D1999) provided on December 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that you received a crown. You also say that this 
should be covered. The Plan denied your request. The Plan says the prefabricated abutment is not listed as a 
covered service. The Plan says that implant supported crown is not listed as a covered service. The Plan also 
says the unspecified preventive service is not listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not 
among those covered under this benefit. The Evidence of Coverage clearly states that if a service is not listed as 
covered, you will have to pay the full cost. Therefore, we decided that the Plan does not have to pay for the 
prefabricated abutment (D6056), implant supported crown (D6065), and unspecified preventive service 
(D1999) provided on December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from November 6, 2020, to 
November 13, 2020, and billed with DRG (diagnosis related group) 521. 
 
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your 
request. The Plan says the documentation supports DRG 522 rather than 521. 
 
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 521, hip replacement with principal diagnosis 
of hip fracture with major complications or comorbidities. 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. Our reviewer says that the billed DRG is not supported. Our physician reviewer found 
the documentation does not include enough evidence to support the secondary diagnosis I21.4, non-st elevation 
myocardial infarction.  Type 2 mycardial infarction (MI) is defined by a rise and fall of cardiac biomarkers and 
evidence of ischemia without unstable coronary artery disease (CAD), due to a mismatch in myocardial oxygen 
supply and demand.  Myocardial injury is similar but does not meet clinical criteria for MI.  
 
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 care provided from November 6, 2020, to November 13, 2020, and billed with DRG (diagnosis 
related group) 521.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210), alveoloplasties in 
conjunction with extractions (D7310), deep sedation/general anesthesia (D9222), and therapeutic parenteral 
drug (D9610) provided on April 14, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the surgical extractions, alveoloplasties, deep sedation/general anesthesia, and 
therapeutic parenteral drug. You say that you believe these services were medically necessary and should be 
covered at 45% by the Plan for the provider being considered out-of-network. The Plan denied your request. 
The Plan says these services are not allowed because they were performed by a provider who has chosen to opt 
out of Medicare. The Plan also says that you contacted the Plan prior to this date of service and were given the 
names of in-network oral surgeons in your area. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received by a provider who has opted out of Medicare. The record shows that you 
signed a private contract with the provider, which shows you will be fully responsible for payment of the 
services rendered by this treating provider, and that no claims will be submitted to your insurance for 
reimbursement. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210), 
alveoloplasties in conjunction with extractions (D7310), deep sedation/general anesthesia (D9222), and 
therapeutic parenteral drug (D9610) provided on April 14, 2021 by a Medicare opt out provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on April 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was prescribed the device to 
prevent the formation of blood clots. The Plan denied your request. The Plan says the codes were not billed in 
compliance with Medicare rules. 
 
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. Items that are used for a preventative service or function are 
excluded from coverage under the Medicare DME benefit. 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 pneumatic compression device and related supplies provided on April 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested services 
are medically reasonable and necessary. The Plan denied your request. The Plan says the benefit for routine 
transportation has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 cannot stay in the hospital too much 
longer and requires additional rehab care to regain their strength. The Plan denied your request. The Plan says 
the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in 
another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on May 14, 2021. 
 
You asked the Plan to pay for subsequent hospital care provided on May 14, 2021. You say that the services 
provided were prior to hospice enrollment. The Plan denied your request. The Plan says when a hospice 
election is in effect, Medicare Fee for Service retains payment responsibility for all hospice and non-hospice 
related claims beginning on the date of the hospice election. This means that the date that a Medicare 
beneficiary elects hospice, all claims for hospice and non-hospice related services should be billed to Original 
Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care and laboratory services provided on 
May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor (CPT code E0667) and pneumatic compressor, segmental home model without calibrated gradient 
pressure (CPT code E0651), for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the enrollee has secondary lymphedema and has 
tried elevation, exercise, and compression for four weeks with no improvement. The Plan denied your request. 
The Plan says there was no detailed assessment done by the prescribing physician at the beginning or end of a 
four-week trial. The Plan states although they have subjective documentation that the enrollee has tried 
elevation, exercise, and used compression garments for four weeks, there is no objective measurements of the 
extent of the lymphedema before or after a trial of conservative treatments. The Plan states measurements of 
the lower extremities were taken on May 17, 2021. The Plan states there are no other measurements 
documented before or after this date of service. The Plan states they reached out to the prescribing provider to 
obtain additional information and inquired about additional lower extremity measurements taken. The Plan 
states additional progress notes submitted do not document an objective baseline/measurements nor progress 
data of the enrollee's response to a four-week trial. 
 
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 DME. physician reviewer found it 
was documented that they had failed conservative therapy, however, more specifics were not seen in the 
documentation such as before and after treatment leg measurements, edema severity to confirm this failure. 
Therefore, without sufficient evidence of failure of a trial of more conservative treatments, this request for a 
segmental pneumatic appliance and compressor will be considered not medically necessary based on the 
provided documentation. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667) and 
pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651), for the 
enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ground mileage (A0425) and non-
emergency ambulance transportation (A0428) provided on November 14, 2020. 
 
You asked the Plan to waive the copayment for the ground mileage and non-emergency ambulance 
transportation. The Plan denied your request. The Plan says the enrollee is responsible for a $250 copay for 
ground travel ambulance services, but because the cost share was less than the standard copay, you paid the 
lesser amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ground travel for Ambulance services.  
 
The enrollee has been asked to pay less than a $250 copay for ground travel for the ground mileage and non-
emergency ambulance transportation because the cost share was less than the standard $250 copay. The ground 
mileage and non-emergency ambulance transportation falls within the Ambulance services benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ground mileage (A0425) and non-
emergency ambulance transportation (A0428) provided on November 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spinal fusion surgery (22214, 22585, 22614, 
22848, 22853). 
 
You asked the Plan to pre-approve lumbar spinal fusion surgery. You say that this surgery is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 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 lumbar spinal fusion surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the criteria for lumbar fusion not met. There is no documentation of spinal 
instability, fracture, or lesion. Therefore, the requested surgery is not medically reasonable and 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 lumbar spinal fusion surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar spinal fusion surgery (22214, 22585, 22614, 22848, 22853).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from August 22, 
2020 to August 26, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of DRG 871 with principal diagnosis code A41.9. The Plan denied your request. The Plan says the 
medical records do not support the billing of DRG 871 with principal diagnosis code A41.9. 
 
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 principal diagnosis code A41.9: 
Sepsis, unspecified organism. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services. Our reviewer says that the medical records do not support the billing of DRG 871 with 
principal diagnosis code A41.9 Our physician reviewer found the enrollee presented to the emergency 
department with urinary retention. Vital signs on arrival were Temp 100.4, heart rate 108, blood pressure 
121/67, and SpO2 96%. Bladder scan revealed 655ml and foley catheter was placed. CTA chest showed 
posterior consolidations and the enrollee was treated for aspiration pneumonia with IV Vancomycin, IV Zosyn, 
PO Augmentin and supplemental O2. Appeal letter notes hypotension, tachycardia, and fever on arrival. While 
member presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening 
organ dysfunction due to a dysregulated host response to infection. Creatinine was 0.69-0.72mg/dL. Platelets 
were 176. Bilirubin was 1.2mg/dL and emergency department provider notes "CMP unremarkable". Bilirubin 
was not reevaluated. The enrollee is nonverbal at baseline; throughout admission the enrollee's neuro status was 
documented as "mental status at baseline." ABG is absent from the record. There was no clinical or laboratory 
evidence of sepsis. The review has determined that the medical records did not support the billing of DRG 871 
with principal diagnosis code A41.9: Sepsis, unspecified organism.  
 
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 hospital services provided from August 22, 2020 to August 26, 2020.