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

 
We decided that the Plan does not have to pay for inpatient services provided from October 5, 2021, through 
October 6, 2021, at DRG 682. 
 
You asked the Plan to pay for inpatient services at DRG 682. You say that the enrollee was admitted due to 
acute kidney failure, dehydration, metabolic encephalopathy, diabetes mellitus, essential hypertension and 
unspecified dementia. You say that N17.9 was accurately submitted as the principal diagnosis code with 
G93.41 as a secondary diagnosis code. The Plan denied your request. The Plan says the medical record does 
not validate the diagnosis of acute kidney failure and metabolic encephalopathy. 
 
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 N17.9, defined as acute 
renal failure, unspecified and secondary diagnosis code G93.41, defined as metabolic encephalopathy. 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 services at DRG 682. Our reviewer 
says that the documentation does not support principal diagnosis code N17.9 and secondary diagnosis code 
G93.41. Our physician reviewer found that while the physician documented the diagnosis of acute kidney 
injury, the medical record does not sufficiently support this condition as being present at the time of this 
encounter.  
 
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 services provided from October 5, 2021, through October 6, 2021, at DRG 682.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics rendered on March 9, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you assumed the orthotics would be covered. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics rendered on March 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telephone evaluation and management 
service by a physician provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that this was not a telehealth visit, 
it was in regard to switching medications. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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). Your contract with the Plan clearly says that you must pay a $50 
copayment for each telehealth visit with a specialist.  
 
You have been asked to pay a $50 copayment for a telehealth visit with a specialist. The telehealth visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits 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 the telephone evaluation and management service by a physician 
provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. You asked the Plan to pre-approve a power wheelchair. You say that the device will aid the enrollee in 
accomplishing his daily activities. The Plan denied your request. The Plan says the enrollee can use a cane or 
walker to get around. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
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 power wheelchair. Our physician 
reviewer found that the documentation is not clear that the home is appropriate for a requested mobility device 
for all MRADL participation as the enrollees bathroom does not provide adequate access for use of the 
wheelchair that is requested. Without evidence that the wheelchair will provide adequate space in the bathroom 
it is not clear that the requested wheelchair will significantly improve participation in all MRADLs in the 
home. Furthermore, the documentation is conflicting. The evaluation states that the device will help the 
enrollee access all rooms independently, which contradicts the home evaluation which states the home is 
accessible for a scooter, but the bathroom is not accessible and there are no dimensions listed. The evaluation 
states the enrollee has fallen once in the past 6 months, while the physician document on the same date states 
the enrollee has no history of falls. The documentation is not clear how an accurate strength grading was 
determined on a telehealth physician visit. The documentation does not reveal a trial of an optimally configured 
manual wheelchair. The evaluation states MRADLs are minimal assist and the physician evaluation states the 
MRADLs are performed at moderate assist. The documentation does not sufficiently support the need for the 
requested power mobility device. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
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 LTACH is the appropriate level of care 
for this enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and does not require transfer to an LTACH. 
 
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 that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The health plan has approved ongoing care in the current acute care setting. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complex electron treatment for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary to prevent 
development of gynecomastia. The Plan denied your request. The Plan says the model policy, which reflects 
the evidence-based consensus opinion of the radiation oncology community, does not support the use of SBRT 
for the prophylactic treatment of gynecomastia. 
 
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 the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no justification provided for this request. It is unclear if the incorrect billing codes were 
submitted, as the case records indicate that the denial is based on a lack of need for stereotactic body radiation 
therapy (SBRT), although complex electron treatment was actually requested by the provider in the pre-
approval form. 
 
 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve complex electron treatment for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
December 14, 2021. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breo Ellipta. 
 
You asked the Plan to pre-approve Breo Ellipta. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Breo Ellipta.  
 
Benefits for Breo Ellipta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and chiropractic services provided from March 
12, 2022, to April 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and chiropractic services. You say that you visit this provider 
because you have, among other conditions, severe osteoarthritis. You also say that after visiting the 
chiropractor he recommended these therapies. You also say that your health condition has greatly improved 
with this treatment. The Plan denied your request. The Plan says according to their systems, it was found that 
the claim does not meet criteria for approval. The Plan also says that the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and chiropractic services provided 
from March 12, 2022, to April 26, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77067 and 77063 billed for date of service 
June 15, 2021. 
 You asked the Plan to pay for procedure code 77067 and 77063. You say that you disagree with the denial. The 
Plan denied your request. The Plan says payment for codes 77067 and 77063 is bundled into payment for code 
77066. 
 
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 codes 
77067 and 77063 are column II codes to column I code 77066. 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 procedure code 77067 and 77063 billed for 
date of service June 15, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain before and after 
contrast. 
 
You asked the Plan to pre-approve an MRI of the brain. The Plan denied your request. The Plan says that the 
provided documentation does not support the medical necessity of the requested imaging. 
 
The Plan follows Medicare rules. Medicare rules say that inconclusive findings on a CT scan may warrant an 
MRI study, and conversely, findings of an MRI study may be further clarified with a subsequent CT scan. 
 
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 an MRI of the brain. Our reviewer says 
that an MRI of the brain is medically reasonable and necessary. Our physician reviewer found while a CT was 
unremarkable, an MRI is generally regarded as a more sensitive form of imaging. Performance of an MRI 
would therefore be readily consistent with the generally accepted standards of practice/care. Our reviewer also 
found that as such, it would be eligible for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the brain before and after contrast.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance service, basic life support, emergency transport 
(A0427), and ground mileage (A0425) provided on November 3, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was transported by ambulance 
at the direction of the physician. You also say that the ambulance services were medically necessary. The Plan 
denied your request. The Plan says that the ambulance services were not medically necessary. 
 
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 file does not support the Plan's reason for denial. Therefore, we 
decided that the Plan has to pay for the ambulance service, basic life support, emergency transport (A0427), 
and ground mileage (A0425) provided on November 3, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary. 
 
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 enrollee is medically stable and does not need a physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs are identified or documented. At the current functional level, the enrollee does not need 3 hours a day x 5 days a week of 
therapies. The documentation does not support the medical necessity due to lack of medical complexity and 
nursing needs, and high functional level for admission to an IRF. While the enrollee would benefit from 
physical therapy and the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on November 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the medical records 
provided are missing a lab order or requisition documenting the billed tests were ordered from the referring 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. 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 drug testing services provided on November 19, 2021.