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

 
We decided that the Plan does not have to pay for inpatient hospital services provided from June 28, 2021, to 
June 4, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the hospital services at the DRG originally billed. You say that these diagnoses 
were supported, so this claim should be paid at the DRG originally billed. The Plan denied your request. The 
Plan says the diagnoses of acute and chronic respiratory failure with hypoxia (J96.21) and acute and chronic 
respiratory failure with hypercapnia (J96.22) are not supported in the medical record, resulting in a lower DRG. 
 
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 diagnosis codes of of acute and chronic respiratory 
failure with hypoxia (J96.21) and acute and chronic respiratory failure with hypercapnia (J96.22). 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 hospital services at the DRG originally billed. Our 
reviewer says that the diagnoses of acute and chronic respiratory failure with hypoxia (J96.21) and Acute and 
chronic respiratory failure with hypercapnia (J96.22) are not supported in the medical record. Our physician 
reviewer found the patient initially presented for outpatient surgery due to a bladder tumor. The patients past 
medical history included coronary artery disease, hypertension, diabetes mellitus type II, fibromyalgia, 
gastroesophageal reflux disease, hyperlipidemia, hypothyroidism, morbid obesity, and obstructive sleep apnea. 
On June 30, 2021, the patient underwent cystoscopy with transurethral resection of bladder tumor and ureteral 
stent placement. Postoperatively, the patient was noted to be hypoxic with oxygen saturations in the low 80's on 
room air. Due to the patient not being able to be titrated off of her oxygen, the hospitalist team was asked to 
admit the patient for further evaluation. The patient was admitted and diagnosed with acute chronic obstructive 
pulmonary disease. While documentation also indicated diagnoses of acute on chronic hypoxemic respiratory 
failure and probably acute on chronic hypercapnic respiratory failure, the clinical evidence did not support the 
conditions.  
 
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 June 28, 2021, to June 4, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this device is not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator implant trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator implant trial. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 spinal cord stimulator implant trial. 
Our reviewer says that the services are medically necessary] Our physician reviewer found the enrollee meets 
the criteria for a lumbar spinal cord stimulator trial. The request is 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 a spinal cord stimulator implant trial have been met. Therefore, we decided that 
the Plan has to pre-approve a spinal cord stimulator implant trial.  
 
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 waive the copayment for a specialist telehealth visit provided on 
February 15, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you never paid for 
telehealth visits before. 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 $30 
copayment for telehealth services with a specialty physician.  
 
The file shows that the Plan noted previous cost shares were waived under COVID-19 guidelines. However, 
this cost share waiver was no longer in effect for this date of service. Therefore, you have been asked to pay a 
$30 copayment for the specialist telehealth visit. The specialist telehealth visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 a specialist telehealth visit provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hemodialysis services provided on November 1, 2021. 
 
You asked the Plan to pay for hemodialysis services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the claim does not include HCPCS code 90999. 
 
The Plan must follow Medicare rules. Medicare rules say that all ESRD hemodialysis claims must include 
HCPCS 90999 on the line reporting revenue code 082x. 
 
We looked at the file and Medicare rules. In this case, code 90999 has not been billed. Based on this 
information, we decided that Medicare rules for coverage of hemodialysis services have not been met. 
Therefore, we decided that the Plan does not have to pay for hemodialysis services provided on November 1, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Taxol for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that these drugs are helpful when you've tried but not had 
a positive response to another anti-PD1 drug. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that PD inhibition 
has been already failed with Imfinzi. Thus, a Keytruda-based regimen is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda, Carboplatin, and Taxol for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bioimpedance spectroscopy (BIS (procedure code 93702) 
provided to the enrollee on January 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the submitted records do not show any evidence of CPT 93702 being performed. 
 
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, the CPT Code Manual definition of code 93702 is "Bioimpedance spectroscopy (BIS), 
extracellular fluid analysis for lymphedema assessment(s)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the submitted records do not 
show evidence that CPT 93702. There were no results provided. The review has determined that the records do 
not support that CPT 93702 was rendered in this case. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for bioimpedance spectroscopy (BIS (procedure code 93702) provided to the enrollee on January 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record sent by your provider 
indicates that the enrollee has non-healing wounds due to a vasospastic condition and hyperbaric oxygen 
therapy has been recommended. The review has determined that the enrollee does not meet the criteria detailed 
in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lap sleeve gastrectomy (43775) provided on November 
18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the gastrectomy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not 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 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 lap sleeve gastrectomy (43775) provided on 
November 18, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and wound care provided on March 25, 2022, 
to March 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and wound care. You say that the doctor you have been visiting 
does not accept your plan and is the only provider in your area that provides wound care. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit and wound care. We found no exception that would require the Plan to pay for the office visit and 
wound care. The records provided for review do not show that the office visit and wound care were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the office visit and wound care provided on March 
25, 2022, to March 29, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on February 16, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the medically necessary ambulance services 
were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the ambulance 
services are not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) were contraindicated for the enrollee. The reviewer found the documentation does not support 
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide for safe transport. The reviewer also found that the documentation does not 
support that the ambulance transport on February 16, 2022, was 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 the ambulance service have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided on February 16, 2022.
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 you really need this high intensity therapy. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 you are medically stable and do not need rehabilitation physician supervision 3 times 
per week for the ongoing management of any active or acute exacerbations of your conditions. While you may benefit from continued physical and occupational therapy, your rehabilitation needs can be safely provided in a 
lower intensity alternate setting such as a skilled nursing facility (SNF). 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services (11056 & G0127) provided on March 
30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that the facility's authorization could be used to 
authorize these services. The Plan denied your request. The Plan says the referring physician and the provider 
of these services are out-of-network and were not 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 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 podiatry services (11056 & G0127) provided 
on March 30, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000) provided on February 2, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you have plantar fasciitis and have had it since 2008 
and had orthotics since then. They have worn out and you started feeling heal pain again. 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 foot orthotics (L3000) provided on 
February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
22, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you would not have the test done 
if you knew your doctor was no longer seeing patients. 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 $5 
copayment for diagnostic lab services and diagnostic procedures and tests.  
 
You have been asked to pay a $5 copayment for the lab services. The lab services fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on February 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical services (62305, 85027, J2405, 
72129) provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for the surgical services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $400 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $400 copayment for the surgical services. Surgical services fall within the 
Outpatient hospital services 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 surgical 
services (62305, 85027, J2405, 72129) provided on March 18, 2022.