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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 17, 2021, to 
January 22, 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 it is felt 
that the reported diagnoses are supported. The Plan denied your request. The Plan says the DRG was reduced 
for this admission as the secondary diagnosis F33.0 was not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code F33.0, defined as major 
depressive disorder, recurrent, mild. 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 reported secondary 
diagnosis is not supported in the records. Our physician reviewer found the enrollee was admitted to the 
hospital with pain due to endophthalmitis and underwent drainage of the left eye. "Major Depressive Disorder, 
Recurrent, Mild" was generated into the "Active Problems" list within the medical record; however, there was 
no physician mention of this specified depressive disorder. Furthermore, there were no medications 
administered relevant to a depressive disorder; there was only mention of a Bupropion prescription, which the 
member was not complying with, for chronic anxiety. There was no physician documentation to support mild 
recurrent major depressive disorder as a valid diagnosis. There was no clinical evaluation, therapeutic 
treatment, or diagnostic procedures relevant to a mild recurrent major depressive disorder diagnosis. The 
review has determined that the records did not support that the secondary diagnosis (F33.0(Major depressive 
disorder, recurrent, mild)) is appropriate for the hospital stay.  
 
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 January 17, 2021, to January 22, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with a psychologist provided on April 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON psychology visit. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 provider in this case is not a network provider with the Plan. 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 the office visit with a psychologist provided on April 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on June 5, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you had the ventilator for one month and 
only used it once before it was returned, so you do not feel that you are liable for the cost-share. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered durable medical equipment and related supplies.  
 
You have been asked to pay a coinsurance of $210.20, which is 20% of the allowed amount for DME 
($1,051.02 allowed x 20% = $210.20). This item/service falls within the Durable Medical Equipment (DME) 
and Related Supplies 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 DME 
provided on June 5, 2022.  
 Your complaint about only using the durable medical equipment one time is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus Homologous Recombination Deficiency (HRD) testing 
provided on May 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for lab tests must 
always be the date the sample was collected. 
 
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 testing at issue is a molecular pathology service provided by a non-blood 
bank. The sample taken was of a lung tumor. The Plan has not submitted evidence that this sample was not 
taken during an outpatient hospital encounter. As such, we find that the determination that the reported DOS is 
incorrect has not been supported. Therefore, we decided that the Plan has to pay for the Tempus Homologous 
Recombination Deficiency (HRD) testing provided on May 3, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the LifeVest provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the LifeVest. You say that the Plan's prior authorization process is opaque and 
your organization does not know when authorization is required. The Plan denied your request. The Plan says 
unauthorized, out-of-network items and services are not covered. The Plan says that it confirmed with the 
patient's primary doctor that they did not refer the member to your organization for this item. 
 
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 provider in this case is not a network provider with the Plan. 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 the LifeVest provided on January 28, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory services provided on April 21, 
2022. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that you had services rendered at 
one facility and they sent the lab work to a different facility. 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 30% 
coinsurance for out-of-network Medicare-covered lab tests.  
 
You have been asked to pay a total coinsurance of $17.31, which is 30% of the allowed amount for laboratory 
services ($57.70 allowed x 30% = $17.31). This item/service falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 
laboratory services provided on April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye surgery services provided on March 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye surgery services. You say that you would like this claim reprocessed and 
approved for payment as the services provided were medically necessary. The Plan denied your request. The 
Plan says prior authorization was not obtained for these services rendered by an OON 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 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 the eye surgery services provided on March 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the chemotherapy administration services (96413) provided on April 
18, 2022. 
 
You asked the Plan to pay for the chemotherapy administration services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that the documentation 
provided does not support payment for code 96413 as billed as there is no documented end/stop time 
documented. 
 
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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial 
substance/drug 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the chemotherapy administration services. Our reviewer says 
that the documentation supports the services as billed. Our reviewer found the procedure report describes 
pharmacy dispensed medication at 14:08 on April 18, 2022, and infusion administered April 18, 2022, from 
14:30 to 15:08. In this case, the start and end time is verified in the documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the chemotherapy administration services have been met. Therefore, we decided 
that the Plan has to pay for the chemotherapy administration services (96413) provided on April 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
provided on May 13, 2022. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that you would 
like this claim reprocessed as the services provided were medically necessary. The Plan denied your request. 
The Plan says the services were not medically necessary according to Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that intraoperative neurophysiology monitoring is subject 
to the criteria listed 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 pay for continuous intraoperative neurophysiology 
monitoring. Our reviewer says that the documentation does not support the services provided were medically 
reasonable and necessary. Our physician reviewer found that the enrollee has a diagnosis of primary 
hyperparathyroidism. On May 13, 2022, the enrollee underwent parathyroidectomy with possible 4 gland 
exploration. Intraoperative neurophysiologic monitoring during thyroid surgery is considered reasonable and 
necessary if the monitoring service adheres to the essential standards, and the surgical procedure involves the 
high-risk total removal of a complete lobe of the thyroid, removal of the entire gland, or involves re-entry (re-
operation) to a prior surgical field where scar tissue obscures the visual path of the recurrent laryngeal nerve. 
This was not the surgery being performed 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 continuous intraoperative neurophysiology monitoring have not been met. 
Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology 
monitoring provided on May 13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on May 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. The 
rules also 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. Specifically, the Plan has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the laboratory services (81455) provided on May 19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses you purchased on May 12, 2022, from an out-of-
network provider. 
 
You asked the Plan to pay for the eyeglasses. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says eyeglasses purchased from an out-of-network provider are 
not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyeglasses only when purchased from a network provider.  You did not purchase the 
eyeglasses in question from a network provider. Therefore, we decided that the Plan does not have to pay for 
eyeglasses you purchased on May 12, 2022, from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses you purchased from an out-of-network provider 
on May 2, 2022. 
 You asked the Plan to pay for the out-of-network eyeglasses. You say that you made a mistake by not 
confirming the provider's status. The Plan denied your request. The Plan says eyeglasses purchased from out-
of-network providers are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received from the Plan's designated vision vendor. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the out-of-network eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pay for eyeglasses you purchased from an out-of-network provider on May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab services 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 lab services provided on April 7, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from February 3, 2022, through 
February 24, 2022. 
 
You asked the Plan to pay for the home health services. You say that this was denied due to no NOA being 
filed which is not correct. You have attached evidence to support an NOA was accepted by the Plan in January 
2022 for this admission. The Plan denied your request. The Plan says that this final claim cannot be paid 
without an NOA, which was not filed for this 30-day period. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have been met. Specifically, the HHA provided evidence showing that an 
NOA was submitted for the prior 30-day home health period beginning on January 4, 2022, and that the 
January 4, 2022, claim was paid. An NOA is only required once per home health admission. Another NOA is 
not required for every subsequent episode of care. We find that the Plan has not supported its denial of payment 
of this claim. Therefore, we decided that the Plan has to pay for the home health services provided from 
February 3, 2022, through February 24, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy evaluation, low complexity (first 
physical therapy appointment taking around 20 minutes) (CPT code 97161 X80). 
 
You asked the Plan to pre-approve the physical therapy services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is no physician signature or sign-off on the documentation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with 
outpatient therapies and their caregivers should be independent with a home exercise program. There is no 
documentation of a recent injury or illness. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are not medically necessary. 
Additionally, there is not documentation that a physician has reviewed and accepted the physical therapy plan 
of treatment. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy evaluation, low complexity (first physical therapy 
appointment taking around 20 minutes) (CPT code 97161 X80).