Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 14, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you have provided documentation to 
support the transport. The Plan denied your request. The Plan says you did not bill with a valid diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with three characters are 
included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of 
fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only 
if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required 
for that code, including the 7th character, if applicable. 
 
In this case, you billed with a 3-digit diagnosis code of R05 (cough).  However, this code is just a heading 
code, and it is further subdivided into more specific diagnoses.  As a result, billing of diagnosis code R05 alone 
is not appropriate without additional characters in the code indicating the specific diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6057, D6010, D6060) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D6057, D6010, D6060)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on November 11, 2020. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the documentation did not support how the results of the testing would be used to 
impact management planning of the enrollee's care. This means that the laboratory test at issue in this appeal 
was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on November 11, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on November 1, 2021. 
 
You asked the Plan to pay for the testing services. You say that the documents support medical necessity. The 
Plan denied your request. The Plan says the request does not meet the Medicare rules for testing. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The records provided do not show that the testing was ordered as part of a 
specific treatment plan. Furthermore, the gene panel was not billed with a single code as required. Based on 
this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel testing provided on November 1, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the inpatient hospital services provided from 
November 12, 2021, to November 16, 2021. 
 
You asked the Plan to further pay for the services provided. You say that sepsis was present and clinically 
validated. The Plan denied your request. The Plan says there is incomplete support of the principal diagnosis. 
 
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 with diagnosis code A41.52, defined as sepsis due to 
pseudomonas. 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 further pay for the services 
provided. Our physician reviewer found that although a diagnosis of sepsis was noted during the stay, 
laboratory data reflected the enrollee was without clear signs of a systemic response. There did not appear to be 
evidence of significant thrombocytopenia, hepatic, or renal dysfunction. The review has determined that the 
records do not support the diagnosis of sepsis due to pseudomonas.  
 
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 
further pay for the inpatient hospital services provided from November 12, 2021, to November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service March 22, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services are supported in the 
medical record. The Plan denied your request. The Plan says they have agreed to pay for the drug testing; 
however, this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service March 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 19, 
2022, to April 17, 2022. 
 
You asked the Plan to pay for SNF care. You say that the continued admission to a SNF was medically 
necessary. The Plan denied your request. The Plan says the continued admission to a SNF was 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 pay for 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 the enrollee no longer qualified for SNF coverage after March 18, 2022. The enrollee 
did not have documented skilled nursing needs. The enrollees feeding tube was chronic and established. The 
enrollee did not have documented skilled therapy needs. The enrollee was non-ambulatory and dependent for 
transfers. The enrollee was functioning at/near her baseline. Daily skilled services were not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs were custodial and, as a practical matter, could be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 19, 2022, to April 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to fully pay for the surgical implant placement (D6010), extraction 
(D7210) and unspecified diagnostic procedure (D0999) provided on November 4, 2021. 
 
You asked the Plan to fully pay for the dental services. You say that your coverage for 2021 was $2,000 and 
you should receive an amended amount of an additional $1,000. You say that payment should be corrected. 
The Plan denied your request. The Plan says your maximum benefit for the 2021 plan year has been paid. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $1,000 maximum benefit for the 2021 Plan year was exhausted with the payment of dental services 
provided on November 4, 2021. Therefore, we decided that the Plan does not have to fully pay for the surgical 
implant placement (D6010), extraction (D7210) and unspecified diagnostic procedure (D0999) provided on 
November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided March 28, 2021, to March 30, 
2021. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 services. Our reviewer says that 
the documentation does not support the DRG billed. Our physician reviewer found the documentation does not 
support a manifestation of systemic infection beyond that evidenced by Systemic Inflammatory Response 
Syndrome (SIRS) criteria. The enrollee remained hemodynamically stable throughout admission with no 
documentation supporting a dysregulated host response to infection. Significance of values must be 
documented by the physician post initial IV fluid resuscitation due to infection and not due to another 
underlying condition, be altered from enrollees baseline values, and should be recorded within a 24-hour 
period of each other. Though a diagnosis of sepsis was noted during the stay, laboratory data reflected the 
enrollee was without clear signs of systemic response there did not appear to be evidence of significant 
thrombocytopenia or hepatic dysfunction. Elevated creatinine noted, however this enrollee has end stage renal 
disease and is on hemodialysis. Even though confusion prior to admission at this facility is documented, 
documentation during this admission consistently states "A&OX 3. No documentation of persistent 
hypotension or hypoxia. Blood cultures revealed no growth. Lactate WNL. Skin noted to be warm and dry. 
Therefore, the principal diagnosis code assignment of A41.9, Sepsis unspecified organism is not supported by 
the documentation.  
 
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 the inpatient services provided March 28, 2021, to March 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay separately for procedure code 73564 billed for date of service 
March 17, 2022. 
 
You asked the Plan to pay separately for procedure code 73564. You say that this service is separately payable. 
The Plan denied your request. The Plan says no separate payment is available for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV-
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. We have confirmed that code 73564 is an STV-packaged service 
because it has a status indicator of Q1.  In addition, code 73564 was billed on the same day as code 99283, which has a status indicator of V.  As a result, payment for code 73564 is considered packaged and not 
separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 73564 have not been met. Therefore, we decided that the Plan does not have to pay 
separately for procedure code 73564 billed for date of service March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 19, 2022. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the 
documentation does not support the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the lab testing is not supported in the medical record. Specifically, there are no medical records 
from the treating physician to determine whether the coverage criteria for the billed date of service have been 
met. Therefore, we decided that the Plan does not have to pay for the gene panel testing provided on February 
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that you are requesting an OON provider specialist 
to treat the enrollee. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aortography provided on March 16, 2022. 
 
You asked the Plan to pay for aortography. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the records do not support the use of this code. 
 
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 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
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 aortography. Our reviewer says that this code does not meet 
the Medicare criteria for payment. Our reviewer found the procedure report does not include documentation of 
an abdominal aortography meeting this code's definition. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aortography have not been met. Therefore, we decided that the Plan does not 
have to pay for aortography provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and an unspecified 
preventive procedure (D1999) provided by an out-of-network provider on May 4, 2022, to May 9, 2022. 
 
You asked the Plan to pay for periodontal maintenance and an unspecified preventive procedure. You say that 
you have always had these services paid before. The Plan denied your request. The Plan says the rendered 
dental work is not covered benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) and an unspecified preventive procedure (D1999) provided by an out-of-
network provider on May 4, 2022, to May 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 72170. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the diagnosis codes billed were incorrect since a 
bilateral diagnosis exists. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should bill the appropriate diagnosis 
(ICD-10 CM) code. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the 
left, right or is bilateral. In this case, you billed with two diagnoses: M16.11, defined as unilateral primary 
osteoarthritis, right hip, and M16.12, defined as unilateral primary osteoarthritis, left hip. Based on this, it is 
clear that the condition exists bilaterally.  There is a more appropriate bilateral ICD-10-CM code to use for 
bilateral hip osteoarthritis (M16.0), so that is the diagnosis code that should have been billed on the claim.  The 
Plan has stated that a corrected claim fixing this diagnosis code issue has not been received.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 72170 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 72170 billed for date of service March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has worsening heart failure. 
The Plan denied your request. The Plan says the device is of uncertain value and carries a risk of significant 
complications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure. The clinical study on which the Food 
and Drug Administration (FDA) approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. Nonetheless, 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.