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 October 11, 2021, to 
October 20, 2021, as billed with Diagnosis Related Group (DRG) 071. 
 
You asked the Plan to pay for inpatient care as billed with DRG 071. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 071 is not supported as the principal diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical 
record. The Plan argues that DRG 948 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 071. Our 
reviewer says that the principal diagnosis of metabolic encephalopathy (G93.41) is not supported in the 
medical record. Our physician reviewer found the enrollee was admitted and treated for abdominal pain. He 
was reported to have confusion. Notes revealed that the enrollee was alert and oriented x3 on evaluation and 
was reported to be grossly stable and with likely early dementia. There were no signs or symptoms suggestive 
of metabolic encephalopathy to support this diagnosis for this admission. 
 
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 071 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from October 11, 2021, to October 20, 
2021, as billed with Diagnosis Related Group (DRG) 071.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions (head region; lower extremities; upper extremities; rib cage; abdomen) provided on  
December 14, 2021, and January 8, 2022. 
 
You asked the Plan to pay for chiropractic manipulation of one or more of the extra-spinal regions. The Plan 
denied your request. The Plan says that the Plan only covers manual manipulation of the spine to correct 
subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen) provided on December 14, 2021, and  
January 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on September 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were previously billed and paid. 
 
The Plan must follow Medicare rules. The rules say that if more than one evaluation and management (face-to-
face) service is provided on the same day to the same patient by the same physician or more than one physician 
in the same specialty in the same group, only one evaluation and management service may be reported unless 
the evaluation and management services are for unrelated problems. 
 
We looked at the file and Medicare rules. The file shows that an initial hospital care code was previously billed 
by the same physician for the same date of service at issue and covered by the Plan. The second code cannot be covered. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on 
September 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 2.5MG tablet 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Eliquis is a self-administered drug and does not fall under Part B coverage. 
 
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 Eliquis 2.5MG tablet  
 Benefits for the medication 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are unable to be discharged to your 
home due to your current condition. The Plan denied your request. The Plan says you have exhausted your 100-
day limit for SNF care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from October 12, 2021, 
through May 5, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85045, 87340) provided on December 
17, 2021. 
 
You asked the Plan to pay for laboratory services. You say that there is no contractual agreement in place to 
include these services in the dialysis rate. 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 laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (85045, 87340) 
provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An Office Visit provided on August 17, 2021 to October 12, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for An Office Visit. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for An Office Visit provided on August 17, 2021 to 
October 12, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen for the enrollee. 
 
You asked the Plan to pre-approve Privigen. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not being prescribed for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Privigen. Our reviewer says that 
Privigen is not medically reasonable and necessary. Privigen is not Food and Drug Administration (FDA) 
approved for the enrollees diagnosis. The use of Privigen for iron deficiency anemia, unspecified and vitamin 
B12 deficiency anemia, unspecified is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of Privigen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Privigen for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rinvoq 15MG extended-release tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Rinvoq is a self-administered drug and does not fall under Part B coverage. 
 
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 Rinvoq 15MG extended-
release tablet.   
Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on August 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Loperamide 2MG capsule. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Loperamide is a self-administered drug and does not fall under Part B coverage. 
 
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 Loperamide 2MG capsule.   
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions (head region; lower extremities; upper extremities; rib cage; abdomen) provided on 
November 11, 2021. 
 
You asked the Plan to pay for chiropractic manipulation of one or more of the extra-spinal regions. The Plan 
denied your request. The Plan says all services other than manual manipulation of the spine for treatment of 
subluxation of the spine are excluded when ordered or performed by a Doctor of Chiropractic. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen) provided on November 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional direct skilled nursing services of a registered 
nurse (RN) (G0299). 
 You asked the Plan to pre-approve additional skilled nursing services. The Plan denied your request. The Plan 
says skilled nursing service is not needed. The Plan also says that your needs are met with the Personal Care 
Attendant (PCA) and Adult Day Health (ADH). 
 
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 additional skilled nursing services. Our 
reviewer says that the documentation does not support that you require additional skilled nursing services to 
provide treatment that is medically necessary. Our physician reviewer found you do not require additional 
skilled nursing services to effectively provide treatment, care, and/or services in order to improve your 
condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our 
reviewer found that you have been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. Our physician reviewer also found that the requested home health services are not 
medically 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 additional skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional direct skilled nursing services of a registered nurse (RN) 
(G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from December 10, 2020, to 
December 14, 2020, as billed with Diagnosis Related Group (DRG) 811. 
 
You asked the Plan to pay for inpatient care billed with DRG 811. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 811 is not 
supported as the diagnosis of pneumonia, unspecified organism (J18.9) is not supported in the medical record. 
The Plan argues that DRG 812 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 billed with DRG 811. Our 
reviewer says that the diagnosis of pneumonia, unspecified organism (J18.9) is not supported in the medical 
records. Our physician reviewer found the enrollee had recently completed a course of antibiotics for 
pneumonia prior to this admission. Chest radiography (CXR) was negative on presentation. Due to the negative 
CXR and other supportive objective signs of pneumonia, the diagnosis is not supported for this admission. 
 
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 811 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from December 10, 2020, to December 
14, 2020, as billed with Diagnosis Related Group (DRG) 811.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethason 2MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Dexamethason is a self-administered drug and does not fall under Part B coverage. 
 
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 Dexamethason 2MG tablet.  
 Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide. 
 
You asked the Plan to pre-approve Budesonide. You say that you recommend the use of Budesonide. The Plan 
denied your request. The Plan says Budesonide is a self-administered drug and does not fall under Part B 
coverage. 
 
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 Budesonide.  
 
Benefits for Budesonide 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on October 11, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the cost for a 300 
yard trip is outrageous. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for each ambulance trip.  
 
You have been asked to pay $278.41, which is less than the $350 copayment for the ambulance transportation. 
The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for ambulance transportation services provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided on 
October 18, 2021. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you don't understand 
why your telehealth visits were being covered and then all of a sudden you were charged a copay. The Plan 
denied your request. The Plan says the copayment applied 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 $30 
copayment for each telehealth specialist visit. Due to the unknown nature of the future of the pandemic, the 
Plan ceased waiving cost-sharing for telehealth services unrelated to treatment of COVID-19 effective 
September 30, 2021. 
 
  You have been asked to pay $30 for the telehealth specialist visit. A telehealth visit falls within the 
Physician/practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist telehealth visit provided on October 18, 2021.