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 on August 23, 2021, to 
August 28, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
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 A41.51 and J96.01. 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the submitted records do not support the billing of diagnosis codes A41.51 and J96.01. 
Our physician reviewer found the enrollee presented to the emergency department on August 23, 2021 with 
complaints of nausea, vomiting, and right flank pain. While transient hypoxia was noted as low as 82 percent 
on room air, she only required 1-4L O2 via nasal cannula. The history and physical and physical assessment 
note that she had good air movement with slightly diminished lung sounds over the right lungbase, but was 
without crackles, egophony, or rubs. There was no evidence of a Glasgow Coma Scale (GCS) of less than 15, 
creatinine of 1.2 or greater, or urine output of less than 500 millileters per day. There is no documentation of 
sepsis or respiratory failure. The records do not support the billing of diagnosis codes A41.51 and J96.01.  
 
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 on August 23, 2021, to August 28, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services and skilled 
nursing facility services provided from February 5, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services and skilled nursing facility services. 
You say that you were admitted the second time for COVID-19, which you contracted from two girls put in the 
same room as you from February 5, 2022, to February 8, 2022. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
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 $75 
copayment per day, days 1 to 4 for inpatient hospital care. The Plan contract also says that enrollees must pay a 
$100 copayment per day, days 21 to 100 for a skilled nursing facility.  
 
 You have been asked to pay a $75 copayment per day, days 1 to 3 for inpatient hospital services, which is a 
total of $225 ($75 x 3 = $225). This item/service falls within the for inpatient hospital care benefit category. 
You have also been asked to pay a $100 copayment per day for eight days for skilled nursing facility services 
($100 x 8 = $800). These services fall within the skilled nursing facility 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 inpatient hospital services and skilled nursing facility services 
provided from February 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET); 
metabolic evaluation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that the exam is being requested in the context of a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 imaging is not medically reasonable or necessary. Our physician reviewer found that the guidelines 
specifically cover positron emission tomography/computed tomography (PET/CT) of the brain unless there is a 
documented concern or differential diagnosis of FTD vs. Alzheimer's disease. The review of the records 
including a detailed neurocognitive evaluation did not show any concern of FTD.  Rather there is a clinical 
diagnosis of progressive Alzheimer's disease. 
 
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 brain imaging, positron emission tomography (PET); metabolic evaluation.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx panel provided on April 22, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this testing is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that FANCC genetic testing is not covered per Local Coverage 
Article (LCA) A53628. However, the testing was part of the FoundationOne CDx panel, which is an FDA-
approved, Medicare-covered test, per NCD 90.2. This NCD supersedes the aforementioned LCA. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the FoundationOne CDx panel provided on April 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. As the enrollee in this case was under inpatient status, the lab 
services are not separately 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 August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need more therapy before you are sent home. 
The Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have identifiable skilled nursing service needs but do not have identifiable 
skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis as an 
inpatient in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 cardiac event monitors are covered when 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a recent randomized clinical trial 
found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral 
anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic 
embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. At this 
time, insertion of an ILR would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a normal saline solution (J7050), a 
ferumoxytol injection (Q0138), and an intravenous infusion (96365) provided on May 18, 2022. 
 
You asked the Plan to waive the coinsurance for a normal saline solution (J7050), a ferumoxytol injection 
(Q0138), and an intravenous infusion (96365). You say that you did not realize the cost share would be so high. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 
 
  You have been asked to pay $94.99 in coinsurance, which is 20% of the allowed amount for a normal saline 
solution (J7050), a ferumoxytol injection (Q0138), and an intravenous infusion (96365) ($474.94 x 20% = 
$94.99). This item/service falls within the Medicare Part B non-chemotherapy prescription drugs 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 coinsurance for a normal saline solution (J7050), a 
ferumoxytol injection (Q0138), and an intravenous infusion (96365) provided on May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on December 6, 2021. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says infrared therapy is 
a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). 
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for infrared therapy provided on December 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 16, 2021, to 
February 24, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services at issue were billed correctly. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 secondary diagnosis code G92, defined as Toxic 
encephalopathy. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the inpatient hospital services at issue do not meet 
criteria for payment at the DRG originally billed. Our physician reviewer found that the documented alteration 
in the enrollee's mental status was not significantly worse than the enrollee's baseline at the time of admission 
or during the course of hospitalization, and the record did not reflect a significant improvement with treatment. 
The available records do not support DRG 480 and secondary diagnosis code G92.  
 
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 on February 16, 2021, to February 24, 2021, at the DRG originally 
billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for musculoskeletal procedures (procedure codes 15734, 20999) 
provided to the enrollee on May 10, 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 there is a more appropriate code to use. 
 
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 [Ent is " 
 
CPT 15734: 
 
Muscle, myocutaneous, or fasciocutaneous flap; trunk 
 
CPT 20999: 
 
Unlisted procedure, musculoskeletal system, general  
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 operative report does not 
include sufficient documentation to confirm that a myocutaneous or fasciocutaneous flap and an unlisted 
procedure was performed. 
 
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 musculoskeletal procedures (procedure codes 15734, 20999) provided to the enrollee on May 
10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for the hearing aid purchased on 
July 6, 2022. 
 
You asked the Plan to provide additional reimbursement for the hearing aid. You say that you were told that the 
check was to be paid for this service. The Plan denied your request. The Plan says payment was made in the 
amount of $600 for the hearing aid purchased on March 17, 2020. This is not payable more than once every 3 
years. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to $600 every 3 years. 
 
The file shows that you were reimbursed for this benefit in March 2020. Further payment cannot be made for 
the date of service at issue in this case.  
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not 
have to provide additional reimbursement for the hearing aid purchased on July 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no skilled needs. 
 
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 the services. Our reviewer says that the 
requested home health services are not medically reasonable or necessary. Our physician reviewer found the 
plan has approved partial coverage. There are no documented skilled nursing needs. There are no physician, 
registered nurse, or home health records identified. There is only administrative paperwork available. As such, 
the requested services are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional home health services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the computed tomography (CT) thorax (71260). 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee did not have the CT lung screen that 
was ordered August 11, 2022. The physician ordered the CT thorax w/ contrast in place of the CT lung screen. 
The Plan denied your request. The Plan says that the results of the prior approved study is needed that show the 
need for repeat imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case.] Our physician reviewer 
found the LDCT referenced by the Plan was cancelled and never done. This enrollee has a smoking history of 
13 pack years and is symptomatic with wheezing, COPD and cough as well as weight loss. Thus, he would not 
have qualified for a LDCT exam. The requested CT of the thorax with contrast is an appropriate test based 
upon the enrollee's history and should be approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the computed tomography (CT) thorax (71260).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the suction assisted lipectomy, trunk (15788) and 
excision, excessive skin and subcutaneous tissue (includes lipectomy) hip (15834). 
 
You asked the Plan to pre-approve the surgical procedure. You say that this is medically necessary because you 
get rashes on your rolls. The Plan denied your request. The Plan says liposuction and excessive skin removal is 
considered cosmetic and is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file, and Medicare rules. The records show that the services requested is skin removal with 
liposuction after having weight loss surgery. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the suction assisted lipectomy, trunk (15788) and excision, excessive skin and subcutaneous tissue 
(includes lipectomy) hip (15834).