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

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care 
provided from September 6, 2021, to September 9, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the documentation supports 
the billing of the primary diagnosis, A41.9. The Plan denied your request. The Plan says the provided 
documentation does not support the billing of the principal diagnosis, A41.9, Sepsis, unspecified organism. 
 
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, A41.9, as defined as 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 an additional amount for the 
inpatient care. Our reviewer says that the principal diagnosis is not supported. Our physician reviewer found 
based on the provided documentation, there is nothing that would support the principal diagnosis was 
supported.  
 
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 
an additional amount for the acute inpatient hospital care provided from September 6, 2021, to September 9, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cozaar tablet. 
 
You asked the Plan to pre-approve Cozaar. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Cozaar tablet.  
 Benefits for Cozaar 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for face down recovery support (E1399) provided October 12, 
2021. 
 
You asked the Plan to pay for face down recovery support. You say that you are requesting reimbursement for 
medically necessary equipment. The Plan denied your request. The Plan says the durable medical equipment 
was provided by a non-Medicare certified provider. If you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for face down recovery support (E1399) 
provided October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 86077) provided on 
November 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare guidance says, HCPCS/ CPT Code: 86077. Practitioner Services MUE Values: 1. MUE Adjudication 
Indicator: 2 Date of Service Edit: Policy. You can find this guidance in the MCR MUE Practitioner Services 
Eff 10-01-2021. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(CPT code 86077) provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 87150) provided on 
January 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code 87150) provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 88341) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says with the information they have, they cannot determine how the enrollee came to 
the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services (CPT code 
88341) provided on September 2, 2021, have been met. Information was not provided to verify services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 88341) 
provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing consultation services provided to the enrollee 
on November 12, 2021. 
 
You asked the Plan to pay for the services. You say that the physician provided a statement of medical 
necessity. The Plan denied your request. The Plan says the claim was not coded correctly to allow additional 
payment for the visit. 
 
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 99308 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 15 minutes are spent at the bedside and on the patient's facility floor or unit." 
 We find that CPT code 99308 is not supported in the medical record. Specifically, this service would be 
included in the global package for services received on the same day. 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 skilled nursing consultation services provided to the enrollee on November 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided 
December 15, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have rendered treatment to the 
enrollee in good faith that the service will be reimbursed. The service was provided with no adequate time 
frame to obtain authorization for the service. The Plan denied your request. The Plan says the records do not 
support that the services were medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. There is no order from the enrollee's primary care physician or attending physician for the 
services. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services 
(90837) provided December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that it is medically necessary based on 
spinal stenosis, lumbar region with neurogenic claudication. The Plan denied your request. The Plan says 
epidural steroid injections do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve epidural steroid injections. Our 
reviewer says that epidural steroid injections are not medically necessary. Our physician reviewer found that 
according to the coverage criteria, a patient should be part of an active rehabilitation program, home exercise 
program or functional restoration program. In this case, there is no documentation provided indicating that the 
enrollee is part of an active rehabilitation program, home exercise program, or functional restoration 
program. The review has determined that the requested ESI does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Gardasil 9 vaccine. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is at high risk. The Plan denied 
your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. The 
records show that you have not contracted HPV. Therefore, we decided that the Plan does not have to pre-
approve a Gardasil 9 vaccine.  
 
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fitness program with an out-of-network (OON) fitness 
center. 
 
You asked the Plan to pre-approve an OON fitness program. You say that this is a well-documented program 
for people with Parkinson's disease. The Plan denied your request. The Plan says this program is not covered 
because it is not an in-network fitness center. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when provided at a fitness location from the Plans fitness providers network. 
 
The Plans rules for coverage of gym benefits have not been met because this provider is not part of the Plans 
fitness network. Therefore, we decided that the Plan does not have to pre-approve a fitness program with an 
out-of-network (OON) fitness center.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tumor Origin panel provided on August 6, 2021, billed with code 
81479. 
 
You asked the Plan to pay for the Tumor Origin panel. You say that this is medically necessary testing that 
should be covered. The Plan denied your request. The Plan says that panels of more than one gene tested in 
parallel must be coded with a single panel code. Therefore, this claim was billed incorrectly and cannot be 
approved even if ordered by a network provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the Tumor Origin panel by a contract provider. The file does not show that the 
plan provided notice that the Tumor Origin panel would not be covered. The Plan's denial rationale states that 
panels must be billed with a single panel code, which was done in this case. Under Medicare rules, this means 
the Tumor Origin panel is considered approved by the plan. Therefore, we decided that the Plan has to pay for 
the Tumor Origin panel provided on August 6, 2021, billed with code 81479.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that if you had 
gone to the hospital, they would have needed to reset your heart (cardioversion). You also say that you are 
scheduled for an ablation of the heart and the reset would have postponed the procedure. The Plan denied your 
request. The Plan says the ambulance benefit is a transportation benefit. The Plan also says that if no transport 
occurs, it is not considered to be a Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical knee arthroscopy with meniscal repair medial 
and lateral for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical documentation provided does not substantiate the need for the services 
requested. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding magnetic resonance imaging (MRI) corroboration of a 
meniscal tear. The 3/7/22 MRI demonstrated cartilage fissures involving the midline patella; small joint effusion and Bakers cyst. Additionally, the exam findings note tenderness with a positive McMurrays. There 
is no indication of mechanical issues, such as catching or locking. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested surgical left knee arthroscopy with meniscal repair medial and lateral, in this case, is not medically 
reasonable or 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical knee arthroscopy with meniscal repair medial and lateral for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy (97124) provided on January 20 to January 
26, 2022. 
 
You asked the Plan to pay for massage therapy. You say that the requested therapy was a medical necessity for 
you. The Plan denied your request. The Plan says rules for payment for massage therapy have not been met. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy (97124) provided on January 20 to January 
26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 19, 2021, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that this was billed correctly. The Plan denied 
your request. The Plan says the documentation supports payment for code 99284 only. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
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 ED services as billed. Our reviewer says that the billed 
services are not supported by the records. Our reviewer found Emergency department documentation does not 
support CPT 99285 level of service. The documented history was not comprehensive and there was not 
documented high complexity medical decision making. 
 
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 ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on December 19, 2021, billed with 
code 99285.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there are no services at the LTACH that the patient requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous. Transfer may be considered when treatment has completed. 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 LTACH services.