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

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 17, 2021, to June 
20, 2021, as billed with Diagnosis Related Group (DRG) 682. 
 
You asked the Plan to pay for inpatient care as billed with DRG 682. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 682 is not appropriate as the diagnosis of acute kidney failure, unspecified (N17.9) is not 
supported in the medical record. The Plan argues that DRG 391 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care as billed with DRG 682. Our 
reviewer says that the diagnosis of acute kidney failure, unspecified (N17.9) is not supported in the medical 
record for this inpatient admission. Our physician reviewer found the enrollee presented to the emergency 
department with loose stool, emesis and decreased urine output. Acute kidney failure was not sufficiently 
supported in the provided documentation. Criteria for acute kidney failure includes either 1.5x increase from 
baseline plasma creatinine (Cr) or an increase in serum creatinine by 0.3+ in less than 48 hours. Using the 
provided baseline Cr and documented hospital measurements during his stay, the enrollee does not meet these 
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 inpatient care as billed with DRG 682 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from June 17, 2021, to June 20, 
2021, as billed with Diagnosis Related Group (DRG) 682.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 5, 2022, to 
February 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 5, 2022, to February 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that for claims with dates of service July 1, 2007, and 
after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE. This integration will result in the routing of all institutional outpatient claims, 
including non-OPPS hospital claims, through a single integrated OCE.  
 
We looked at the file and Medicare rules. In this case, multiple visits were reported on the same date with the 
same revenue center. As the services were not billed with revenue code G0, the claim was returned with OCE 
edit 42.  This edit requires the claim to be returned to the provider, and the services are not payable. 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 services provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam with photos (92250) provided on January 4, 
2022. 
 
You asked the Plan to pay for the eye exam with photos. You say that you received a letter stating you did not 
pay the $25.00 for the x-ray, but you did pay for this service. The Plan denied your request. The Plan says this 
service is not covered by your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.   
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the eye exam with photos (92250) provided on January 4, 2022.  
 
Please Note: The records you provided show that you did pay for this service but are still being billed for it. 
You may wish to contact the provider about this issue.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81210, 81235, 81275, 
81276, 81295, 81298, 81317, 81401, 81301, 81191, 81309, 81206, and 81292) provided on February 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 services are 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. Furthermore, the denial 
remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a 
patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a 
single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (CPT code(s): 81210, 81235, 81275, 81276, 81295, 
81298, 81317, 81401, 81301, 81191, 81309, 81206, and 81292) provided on February 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging of the breast (MRI) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a magnetic resonance imaging of the breast (MRI). You say that you are 
dealing with breast cancer, and it is very invasive. You also say that this facility is the one that can do this 
service as soon as possible. You also say that you had to change your primary care physician (PCP) because of 
this issue. The Plan denied your request. The Plan says this provider is outside of the network and is not a 
covered benefit, and there are providers in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a magnetic resonance imaging of the breast (MRI) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 27, 2021, 
to July 28, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission was medically 
necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee's physical exam and labs were 
normal. Therefore, the reviewer found that the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from July 27, 2021, to July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services you received from an out-of-network 
provider on December 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
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 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 hearing aid services you received from an out-of-network 
provider on December 30, 2021.
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 would be at risk for falls if he went home and it 
would be harmful for his health. You say there has been a repeating pattern of going back to the hospital after 
being sent home. The Plan denied your request. The Plan says authorization denied for IRF care because it is 
not medically necessary, and your needs can be met at a lower level of care like a skilled nursing facility 
(SNF). 
 
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 close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no acute nursing needs identified or documented. The complexity of your medical and 
rehabilitation needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitation care. 
 
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: 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 needs inpatient rehabilitation to help get 
him back to his previous ability to function for day to day activities. The Plan denied your request. The Plan 
says authorization denied because the IRF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically improving and does not need close physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic 
medical conditions. The record shows there are no acute nursing needs identified or documented. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on July 10, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical reports support the services 
rendered. The Plan denied your request. The Plan says two separate services were not 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 93971 is duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. The claim information shows that 
CPT code 93971 was billed twice on the same date of service. We find that CPT code 93971 is not supported in 
the medical record. The records do not show that the duplex scan was performed more than once on the date of 
service at issue. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan 
provided on July 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mental health sessions to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the mental health sessions. You say that the OON provider is already 
visiting the enrollee and that the Plan does not have any providers that provide the type of service the enrollee 
needs. The Plan denied your request. The Plan says there are in-network providers that provide the service the 
enrollee needs and can see the enrollee virtually or there are options for assistance with transportation. The 
service is approved but the OON provider was not. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the mental health sessions to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Durolane, 
Monovisc, or Synvisc-One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found there is no indication that the enrollee 
has tried and failed the required drugs. The reviewer also found that there is no indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac joint Radiofrequency ablation (RFA) (64625), 
provided on October 29, 2021. 
 
You asked the Plan to pay for sacroiliac joint RFA. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is experimental. 
 
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 pay for sacroiliac joint RFA. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pay for sacroiliac joint Radiofrequency ablation (RFA) (64625), provided on October 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that this is medically necessary for the 
enrollee's pain management. The Plan denied your request. The Plan says the benefit limit for facet joint 
injections has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than four 
(4) diagnostic joint sessions will be considered medically reasonable and necessary per rolling 12 months 
 
We looked at the file and Medicare rules. In this case, the medical records indicate that 4 facet joint injections 
have already been performed during the rolling 12 month period. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0430) and fixed wing air mileage (A0435 x 2) provided on November 21, 2020. 
 
You asked the Plan to pay for the air ambulance services. You say that the transport was medically necessary. 
The Plan denied your request. The Plan says the transport was not medically necessary. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services are were not medically necessary. Our physician reviewer found the 
provided documentation does support that you suffered from an illness or injury that contraindicates 
transportation by any means other than ambulance. The reviewer also found that the provided documentation 
does not support that the transferring hospital did not have adequate facilities to provide the medical services. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport, one way (A0430) and 
fixed wing air mileage (A0435 x 2) provided on November 21, 2020.