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 to the enrollee from 
September 22, 2021, to September 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 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 DRG 291 (HEART FAILURE AND SHOCK 
WITH MCC). 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 that the review has determined that the records do not support the use of DRG 291 in this case. The 
records did not support the use of diagnosis code J06.01 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 September 22, 2021, to September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orbactiv (J2407). 
 
You asked the Plan to pre-approve Orbactiv. You say that Orbactiv is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 Orbactiv. Our reviewer says that 
Orbactiv is not medically necessary. Our physician reviewer found Dalbavancin (Dalvance) has been approved 
for four months. Orbactiv is considered a duplicate medication, used to treat the same diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orbactiv have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orbactiv (J2407).
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 June 
2, 2021, to June 21, 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 provider has reported inpatient hospital services with the incorrect DRG.  
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 DRG 673 (OTHER KIDNEY AND URINARY 
TRACT PROCEDURES WITH MAJOR COMPLICATION OR COMORBIDITY (MCC)). 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 that there was no specific 
management provided for severe malnutrition. Although the diagnosis of severe malnutrition is documented in 
the  progress note, supporting documentation was not found within the medical records. The note reported "no 
fatigue or weight loss." The review has determined that the records did not support the use of DRG 673 in this 
case. The records did not support the use of diagnosis code E43 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 June 2, 2021, to June 21, 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 
February 19, 2022, to February 20, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says there was no indication of a need for a 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented on 2/19/22 with complaints of slurred speech and 
difficulty expressing thoughts. He was admitted for imaging, neurology and neurosurgical consultation and was 
discharged on 2/20/22. The record does not show that the admitting physician reasonably expects that the 
patients necessary hospital care will span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from February 19, 2022, to 
February 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, 51 or greater 
genes (81455) provided April 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says does not meet Medicare NCD/LCD criteria.  
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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimens were collected 
on March 14, 2022 and March 23, 2022, rather than the billed date of service April 8, 2022. There is no 
documentation to support genetic testing with the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for targeted genomic sequence analysis panel, 51 or greater genes (81455) provided 
April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight psychotropic test provided to the enrollee on 
March 28, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the order was not signed and the claim did not include the Z code. 
 
The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of 
GeneSight testing. 
 
Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the GeneSight psychotropic test provided to the enrollee on 
March 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70470-26 billed for date of service April 29, 
2022. 
 You asked the Plan to pay for procedure code 70470-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70470-26 is bundled into 
payment for code 0042T. 
 
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, we have confirmed that code 
70470-26 is a column II code to column I code 0042T. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70470-26 billed for date of service 
April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine you received on April 22, 2022. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you did not pay for your first shingles vaccine 
several years ago.  You do not understand why your plan will not cover this. The Plan denied your request. The 
Plan says this vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed 
to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the 
Shingles vaccine you received on April 22, 2022.  
 
Benefits for the Shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 23, 2021. 
 
You asked the Plan to pay for the medical services. You say that you submitted this claim timely. The Plan 
denied your request. The Plan says you did not timely file your corrected claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers have 1 year from the date that the 
claim was initially processed to submit a corrected claim.  In this case, this claim was initially processed by the 
Plan on February 25, 2021.  You did not submit a corrected claim until April 28, 2022, outside of the 1-year 
window. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on January 23, 2021.
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 are appealing per the enrollee and family 
request. You say that inpatient rehabilitation is the only option for the enrollee to return home safely. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
inpatient rehabilitation facility. 
 
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 enrollee was admitted for weakness, hypotension, and falls and was 
discharged home on August 22, 2022. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left L5-S1 radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain 
indications. 
 
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 radiofrequency ablation. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had two sacral branches 
ablated. Two sets of diagnostic medial branch blocks are needed, each of which produces 80% pain relief. 
Since this is not documented, the requested services are not a covered benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left L5-S1 radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on June 30, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has hypertension and hyperlipidemia. The record provided is insufficient to demonstrate the medical necessity of the requested service. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on June 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on 
February 7, 2022. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you were not told by the 
provider a copayment was due at time of visit. You say that you disagree with the way the visit is being billed 
as an "outpatient hospital stay" and you were unaware of how expensive the visits were. The Plan denied your 
request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 You have been asked to pay a $125 copayment for an outpatient clinic visit. An outpatient clinic visit falls 
within the Outpatient Surgery, including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers, benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient clinic 
visit provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the initial hospital observation care 
provided on January 31, 2022. 
 
You asked the Plan to waive the deductible for the initial hospital observation care. You say that you are 
appealing this cost-sharing. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to Outpatient Hospital Observation. At 
the time this claim was processed, the $500 deductible had been met. The allowed amount of this claim is 
$182.58, resulting in a deductible amount of $182.58. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Hospital Observation. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$500 deductible which applies to Outpatient Hospital Observation. This cost sharing is a contractual obligation 
that had not been met at the time the initial hospital observation care was received on January 31, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the initial hospital observation 
care provided on January 31, 2022.
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 
November 26, 2021, to December 8, 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 provider has reported inpatient hospital services with the incorrect DRG.  
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 DRG 180. 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 there was no o documentation of change in 
cognition or mental status from his baseline, accessory muscle use, or markedly low oxygenation after initial 
focused treatment in the emergency department. The review has determined that the records did not support the 
use of J96.01 in this case. The records did not support the use of DRG 180 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 November 26, 2021, to December 8, 2021.