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

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from April 7, 2021, to 
April 12, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 871 is not supported as the diagnoses of sepsis, unspecified organism (A41.9), 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. The Plan argues that DRG 178 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. DRG 871 requires a primary diagnosis of sepsis, organism 
unspecified (A41.9), 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 inpatient care billed with DRG 871. Our 
reviewer says that the billed diagnoses at issue in this case are not supported in the medical record. Our 
physician reviewer found that the enrollee presented to the emergency department with complaints of shortness 
of breath. While the blood gas noted an elevated pCO2 of 71 with a pH of 7.30 and an oxygen saturation of 
88% on 3L, the documentation stated that the enrollee had underlying chronic respiratory failure and required 
3L of supplemental oxygen at baseline. In addition, a follow-up blood gas on 04/09/2021 continued to note an 
elevated pCO2 at 64 and a corresponding pH of 7.34, suggesting a chronic compensated state. There was no 
increase in supplemental oxygen from baseline requirements and no evidence to support aggressive treatment 
consistent with a diagnosis of acute respiratory failure. The review has determined that the medical records do 
not support the billing of sepsis, unspecified organism (A41.9), acute and chronic respiratory failure with 
hypoxia (J96.21) and acute and chronic respiratory failure with hypercapnia (J96.22). 
 
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 billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from April 7, 2021, to April 12, 2021, 
as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the F1 heme test provided on September 14, 2021. 
 
You asked the Plan to pay for the F1 heme test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that genetic testing procedures submitted with code 81455 are unlikely to 
impact therapeutic decision-making. 
 
The Plan follows Medicare rules. Medicare rules say that there must be an underlying performance of 
acceptable, high-quality analytical validity for all laboratory testing. 
 
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 F1 heme test. Our reviewer says that the 
requested services performed were medically reasonable and necessary. Our physician reviewer found the F1 
heme test is a comprehensive genomic profiling (CGP) test combining deoxyribonucleic acid (DNA) and 
ribonucleic acid (RNA) sequencing for patients with hematologic malignancies, sarcomas or solid tumors 
where RNA sequencing is desired. The review has determined that the enrollee meets the criteria for this testing. 
 
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 F1 heme test have been met. Therefore, we decided that the Plan has to pay 
for the F1 heme test provided on September 14, 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 inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the records received show that your 
condition has improved, and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you would improve in a reasonable period of time as you do not have suicidal or homicidal 
ideation noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any 
symptoms which would require acute treatment. It does not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have 
dangerousness to self or others and were compliant with your treatment with encouragement. Our physician 
reviewer found that your condition does not meet criteria for coverage of inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation discharge day services (99217) provided on 
October 18, 2021. 
 
You asked the Plan to pay for the observation discharge day services.. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request.  The Plan says a review of the members claims history indicates there was no initial or subsequent observation 
care code reported, or another service resulting in an observation stay reported. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]) 
 
We find that CPT code 99217 is not supported in the record. Specifically, the documentation does not indicate 
that additional observation care codes were reported. Based on this information, we decided that Medicare rules 
for coverage of the observation discharge day services. have not been met. Therefore, we decided that the Plan 
does not have to pay for the observation discharge day services (99217) provided on October 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need routine 
transportation to dialysis treatments. The Plan denied your request. The Plan says that this benefit is exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty (20) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services, medical 
examination and evaluation provided on December 3, 2021. 
 
You asked the Plan to waive the copayment for ophthalmological services, medical examination and 
evaluation. The Plan denied your request. The Plan says the claim processed with the correct copayment. 
 
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 $35 
copayment for Vision Care, Medicare-covered exams to diagnose and treat diseases of the eye, including an 
annual glaucoma screening for members at high risk.  
 
 You have been asked to pay a $35 copayment for ophthalmological services, medical examination and 
evaluation. The ophthalmological services, medical examination and evaluation falls within the Vision Care, 
Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for 
members at high risk 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 
ophthalmological services, medical examination and evaluation provided on December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553), provided on September 21, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the documentation submitted did not include a valid proof of delivery or 
delivery ticket to indicate specific supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vision exam (92004), progressive lens (V2781), anti-
reflective coating (V2750), scratch resistant coating (V2760), frames (V2020), and tint (V2744), provided on 
October 13, 2021, and October 21, 2021. 
 
You asked the Plan to pay for the vision exam and eyewear. You say that you went to the cheaper eye center. 
The Plan denied your request. The Plan says a Plan provider must be used to receive this benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when a plan provider is used to obtain vision services. 
 
We looked at the file and the Plan's rules. You obtained these services through an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of the vision exam and eyewear have 
not been met. Therefore, we decided that the Plan does not have to pay for the vision exam (92004), 
progressive lens (V2781), anti-reflective coating (V2750), scratch resistant coating (V2760), frames (V2020), 
and tint (V2744), provided on October 13, 2021, and October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair (PWC) (K0898), commode chair 
(E0163), and other durable medical equipment (DME) (E1399), provided on October 18, 2021. 
 
You asked the Plan to pay for the PWC, commode chair, and other DME. You say that the items are medically 
necessary. The Plan denied your request. The Plan says you obtained these items through a provider who is not 
enrolled in Medicare. 
 
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 the power wheelchair (PWC) (K0898), 
commode chair (E0163), and other durable medical equipment (DME) (E1399), provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553), provided on March 12, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items were medically necessary. The 
Plan denied your request. The Plan says a valid physician order was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order. There is no indicated the treating physician ordered the 
items or discussed the need for them. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483 and 80307) provided on 
January 5, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 
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 drug testing 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 drug testing services (G0483 and 80307) provided on January 5, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from April 2, 2021, to 
April 5, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not supported as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 189 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. DRG 871 requires a primary diagnosis of sepsis, organism 
unspecified (A41.9). 
 
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 billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the record. Our 
physician reviewer found that the enrollee with a history of lumbar disc disease presented to the emergency 
department on April 2, 2021, with fever, cough, hemoptysis and hypoxia. The evaluation including a computed 
tomography angiography (CTA) showed bilateral ground glass infiltrates in the lungs with a bilateral pleural 
effusion. His white blood cell count was normal; lactic acid 1.3. There was tachycardia and tachypnea. His 
blood pressure was stable. He was treated with intravenous (IV) fluids, oxygen, and IV antibiotics 
(Ceftriaxone/Azithromycin). There was no clinical evidence of sepsis. The review has determined that the 
medical records did not support the billing of sepsis, unspecified organism (A41.9). 
 
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 billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from April 2, 2021, to April 5, 2021, 
as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AlloSure testing (81479) provided on May 14, 2021. 
 
You asked the Plan to pay for the AlloSure testing. You say that you would like reconsideration because this 
testing is medically necessary. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 
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 AlloSure testing 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 AlloSure testing (81479) provided on May 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 9 additional home health physical therapy visits. You say that home health 
physical therapy services are medically necessary. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 9 additional home health physical 
therapy visits. Our reviewer says that the requested home health physical therapy services are not medically 
reasonable and necessary. Our physician reviewer found the enrollee is an 82-year-old male with a past medical 
history of Parkinson's disease, osteoarthritis and Lewy body dementia who has been receiving home health 
physical therapy since November 15, 2021, for functional decline and ambulatory difficulty. Based on the 
medical records provided there is no documentation that further skilled therapy services are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the patient's level of function and/or prevent 
deterioration. As of March 11, 2022, he was walking 200 feet with a rolling walker with contact guard 
assistance and was supervision for most transfers. Provided records do not document any acute or unstable 
medical conditions or changes in medication or treatment which would necessitate any further skilled therapy 
visits beyond what have already been approved. No medical notes from the enrollees treating physician are 
provided documenting a need for additional skilled therapy services. Further utilization of the home exercise 
program with caregiver assistance appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits.