Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation (CPT code 99253) provided on 
October 31, 2021. 
 
You asked the Plan to pay for the inpatient consultation. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99253, is assigned a status code I, which is not valid for Medicare purposes. Medicare uses 
another code for reporting of and payment for these services. Based on this information, we decided that 
Medicare rules for coverage of the inpatient consultation have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient consultation (CPT code 99253) provided on October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjust complete denture - mandibular (D5411) provided 
November 23, 2021. 
 
You asked the Plan to pay for the lower denture adjustment. You say that you feel your dental benefit should 
apply to the claim. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a denture 
adjustment once per calendar year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that an upper denture 
adjustment was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the denture adjustments has been exceeded. Therefore, we decided that the Plan 
does not have to pay for the adjust complete denture - mandibular (D5411) provided November 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
22, 2021, to May 24, 2021. 
 
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 the DRG was adjusted 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.   
 
In this case, you billed the inpatient services provided with 311 (ANGINA PECTORIS). 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our physician reviewer found the enrollee presented to the 
emergency department (ED) on 5/22 with complaints of one episode of chest pain that resolved prior to ED 
arrival. Additionally, she complained of dyspnea on exertion for several months. The enrollee remained chest 
pain-free with a negative cardiac exam and was ruled out for acute coronary syndrome (ACS). She was 
discharged home in hemodynamically stable condition on 5/24/21. The documentation did not meet inpatient 
guidelines, and the right DRG was not used in this case.  
 
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 to the enrollee from May 22, 2021, to May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found Interspinous process spacers remain 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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. Daily skilled services are not 
required. Provided records do not document a significant decline in your functional status compared to your 
recent baseline to necessitate daily inpatient skilled therapy services. You do not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Services in the long-term care facility on a part time 
basis appear appropriate in this case. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from February 3, 2020, 
to February 7, 2020, billed with DRG 871. 
 
You asked the Plan to pay for inpatient services billed with DRG 871. You say that this diagnosis is supported 
in the record, and these services were billed appropriately. 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 record. 
The Plan argues that DRG 195 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 services billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. 
Our physician reviewer found that the enrollee presented to the emergency department with headache, cough 
with yellow sputum and fever. On February 4, 2020, the enrollee was described as nontoxic, and her mental 
status was at baseline. On February 5, she was described as stable; her O2 on 2 liters was stable and oxygen 
weaning started. She was discharged home on February 7, 2020, not on oxygen therapy. There was no clinical 
or laboratory 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 services 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 February 3, 2020, to 
February 7, 2020, billed with DRG 871.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should only require short-term additional 
acute care services to further stabilize until more appropriate for a lower level of care. Care can be safely 
administered at the current facility until this time. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer may be considered when 
treatment has completed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guadrant360 testing (81479) provided on May 14, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this service was billed correctly. The Plan denied your request. The Plan says this claim was not billed with the 
correct 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 Guardant360 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 Guadrant360 testing (81479) provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the eye exam provided on 
October 29, 2021. 
 
You asked the Plan to pay an additional amount for the eye exam. You say that you contacted the Plan's vision 
vendor and they will send you a check for $75; however, you believe the Plan should cover the full balance of 
$291 since you were responsibly going in for a routine, preventive exam. The Plan denied your request. The 
Plan says you were reimbursed according to your out-of-network vision benefit. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that you have been reimbursed $75, which is 
according to your out-of-network vision benefit, and you are responsible for the balance. Therefore, we decided 
that the Plan does not have to pay an additional amount for the eye exam provided on October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should only require short-term additional 
acute care services to further stabilize until more appropriate for a lower level of care. Care can be safely 
administered at the current facility until this time. The enrollee does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to LTACH is not medically necessary at 
this time. Transfer may be considered when treatment has completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to still be somewhat unstable and requires short-term additional 
acute care services to further stabilize until more appropriate for transfer/discharge. Care can be safely 
administered at the current facility until this time. The enrollee does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to LTACH is not medically necessary at 
this time. Transfer may be considered when treatment has completed and the enrollee is more stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for a trigger point injection provided on September 29, 
2021. 
 
You asked the Plan to waive the copayment for an injection. You say that you did not receive the shot at a 
hospital, and the doctor gave you the shot in her office like she always does. You also say that the Plan checked 
and the last time you received this shot was in February 2020, and it was not billed this way. The Plan denied 
your request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 did not provide medical records to show where the services took place. 
Therefore, there is no evidence that you received the injection in an outpatient setting instead of your doctors 
office. Without medical records we are unable to confirm if outpatient hospital cost sharing applies. We 
decided that the Plan has to reduce the copayment for a trigger point injection provided on September 29, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on September 29, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on September 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that proton beam therapy is 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a chest wall recurrence 
of breast cancer after prior breast conserving surgery and adjuvant radiation in 2014. There is no history of 
present illness with the only records being imaging showing a chest wall mass invading the pectoralis major 
and minor muscles and satellite nodules, a biopsy showing recurrent cancer, and an ultrasound on January 12, 
2022 showing no sonographic evidence of recurrence. In the absence of records supporting the need for 
radiation therapy in this enrollee, which would not be standard of care in lieu of mastectomy, or any literature 
supporting the medical necessity of definitive radiation in this setting, the services are not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelet-rich plasma injections (0232T) provided from 
December 1, 2020, to December 23, 2020. 
 
You asked the Plan to pay for platelet-rich plasma injections. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that platelet-rich plasma (PRP), an autologous blood-
derived product, will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure 
wounds and only when the patient is enrolled in a clinical trial. 
 
We looked at the file and Medicare rules. The submitted documentation does not show that you had qualifying 
non-healing wounds or were enrolled in a clinical trial. Based on this information, we decided that Medicare 
rules for coverage of platelet-rich plasma injections have not been met. Therefore, we decided that the Plan 
does not have to pay for platelet-rich plasma injections (0232T) provided from December 1, 2020, to December 
23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 6, 2020, to September 9, 2020. 
 
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 the DRG was updated 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.   
 
In this case, you billed the inpatient services provided with . 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 services. Our reviewer says that the services at issue in this case were not supported by 
the medical records. Our physician reviewer found the medical record received and available for review does 
not support the condition treated as consistent with a systemic infectious process. The review has determined 
that payment of DRG 872 is not supported. The review supports DRG 690.  
 
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 to the enrollee from September 6, 2020, to September 9, 2020.