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

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay provided on April 
06, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you shouldnt have to pay 
for this. 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 10% 
coinsurance for Inpatient hospital care. 
 
You have been asked to pay 10% coinsurance for inpatient hospital stay. This item/service falls within the 
Inpatient hospital care 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 inpatient 
hospital stay provided on April 06, 2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
November 19, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service is not related to 
the enrollee's hospice diagnosis. You also say that this should be reprocessed and paid. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 17, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge day management (99239) provided on November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient care is medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have no specified active medical comorbidities. The complexity of your 
nursing, medical and rehabilitation needs would not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 8, 2021, to 
December 10, 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 Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 A41.9, defined as sepsis, unspecified organism. 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 documentation does not support the diagnosis billed. Our physician 
reviewer found the enrollee has gastroparesis and was treated in the hospital. The enrollee presented with 
nausea and vomiting. Vitals were stable, although blood pressure was low requiring fluids initially in the 
emergency department. Examination revealed sleepiness, but otherwise unremarkable. Labs were significant 
for Leukocytosis, platelets normal, high glucose of 743, normal bilirubin, procalcitonin of 13, and lactic acid of 
4.1. The enrollee was diagnosed with diabetic ketoacidosis (DKA) and infectious workup negative. The 
enrollee was started on antibiotics empirically, insulin, and IV antiemetics with the enrollee's condition 
improving. The enrollee did not experience persistent hypoxia. The enrollee's kidney injury and hypotension 
could have been directly related to DKA. Sepsis is not sufficiently supported here as there was no clear 
infectious process found and there were insufficient signs of organ failure due to a dysregulated response to 
infection as required for sepsis 3 criteria. Therefore, the sepsis diagnosis was not appropriate for this 
admission.   
 
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 December 8, 2021, to December 10, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance used with a therapeutic CGM device 
(K0553) provided August 8, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that the enrollee owns the K0554 Freestyle Libre 2 
reader since December 6, 2021. The K0553 Freestyle Libre 2 sensors is needed every 30 days per Medicare 
guidelines. The Plan denied your request. The Plan says the documentation does not support the payment. 
 
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, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the proof of delivery indicates the package was 
hipped on August 1, 2022, and delivered on August 4, 2022, however the included packing slip and claim 
image have the service date August 8, 2022. 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 
supply allowance used with a therapeutic CGM device (K0553) provided August 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex system. 
 
You asked the Plan to pre-approve a Vertiflex system. You say that the requested procedure has been 
authorized by administrative law judges and is not investigational. You say that the Plan should cover this 
procedure, as Original Medicare would. The Plan denied your request. The Plan says the requested procedure 
has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that 
interspinous spacer devices are as safe and effective as the gold standard of decompression. 
 
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 a Vertiflex system. Our reviewer says 
that a Vertiflex system is not considered medically reasonable and necessary in this case. Our physician 
reviewer found a Vertiflex system 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 a Vertiflex system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95907, 95886, and 95937 provided on May 20, 2022. 
 
You asked the Plan to pay for codes 95907, 95886, and 95937. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the records do not support the billed codes. 
 
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 the codes at issue are as follows: 
- 95907 nerve conduction studies; 1-2 studies 
- 95886 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with 
nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by 
three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
- 95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 codes 95907, 95886, and 95937. Our reviewer says that the 
records do not support the use of these codes. Our reviewer found, for code 95907, the procedure report does not include sufficient documentation to confirm, per NCCI Policy, "Electrodes are placed directly over the 
nerve, in sensory conduction testing, or over the motor point of a specific muscle in motor conduction testing. 
Electrical stimulation is applied. The latency, amplitude, and conduction velocity of the stimulation are 
measured." The procedure report documents, Sensory Nerve Action Potential (SNAP) demonstrated adequate 
stimulation to produce waveform. Therefore, nerve conduction studies cannot be verified. For code 95886, the 
procedure cannot be verified as nerve conduction studies are not documented in the procedure report. For code 
95937, the procedure report describes train of four being reported with Neuromuscular Junction testing, which 
is the incorrect code to report for this procedure. Also, train of four testing is included in the primary 
neuromonitoring procedure code and reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95907, 95886, and 95937 have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 95907, 95886, and 95937 provided on May 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug tests, definitive, 15-21 classes provided on January 25, 2022. 
 
You asked the Plan to pay for the testing for 15-21 classes of drugs. You say that this claim should be paid. The 
Plan denied your request. The Plan says that only 7 classes of drugs were tested. 
 
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 G0482 is drugs testing of 15-21 classes. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, we reviewed the drugs tested 
and found that 16 classes of drugs were tested. Based on this information, we decided that Medicare rules for 
coverage of the testing for 15-21 classes of drugs have been met. Therefore, we decided that the Plan has to pay 
for the drug tests, definitive, 15-21 classes provided on January 25, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
16, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure to bilateral 
S1-S2-S3 innervating the sacroiliac (SI) joint (64625). 
 
You asked the Plan to pre-approve an RFA procedure to bilateral S1-S2-S3 innervating the SI joint. You say 
that this RFA procedure has been successful in the past, and you would like it to be approved for coverage. The 
Plan denied your request. The Plan says ablation procedures are not supported by research to treat pain in the 
joint that connects the pelvis to the tailbone (sacroiliac pain). 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacroiliac joint 
pain is considered not medically necessary/investigational. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an RFA procedure to bilateral S1-S2-S3 innervating the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure to bilateral S1-
S2-S3 innervating the sacroiliac (SI) joint (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you and your family feel that inpatient rehabilitation 
would benefit and help you to recover quicker. The Plan denied your request. The Plan says intensive 
rehabilitation service is not considered medically reasonable or necessary based on Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a femur fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 13, 2022, billed with 
codes 81401, 81403, 81405, 81406, 81407 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. In addition, there is insufficient evidence to show that this testing was medically necessary. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 13, 2022, billed with codes 81401, 81403, 81405, 81406, 81407 and 81408.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found further 
improvement in the patient's functional status does not appear to be predictable in a reasonable time frame to 
necessitate additional skilled therapy services beyond what have already been approved. The Provided records 
do not document any acute or unstable medical conditions or injuries which would necessitate any further 
skilled therapy visits beyond what have already been 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic colonoscopy (45378) provided on February 
28, 2022. 
 
You asked the Plan to pay for the diagnostic colonoscopy (45378). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 7, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the diagnostic colonoscopy (45378) have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic colonoscopy (45378) provided 
on February 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional course of treatment with Tepezza (J3241). 
 
You asked the Plan to pre-approve Tepezza. You say that the enrollee requires additional treatment. The Plan 
denied your request. The Plan says the requested additional treatment is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Tepezza. Our reviewer says that 
additional treatments of Tepezza are not medically necessary. Our physician reviewer found the drug 
manufacturer and the Medicare-approved major drug compendia state that 8 Tepezza infusions total, including 
the initial dosage, are recommended for treatment of the enrollee's condition. Therefore, the reviewer found 
that more than 8 infusions with Tepezza is not medically reasonable and 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 Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an additional course of treatment with Tepezza (J3241).