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 03, 2022, 
through January 08, 2022, and billed with diagnosis code J96.01. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.01 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.01. 
 
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 J96.01- (Acute 
respiratory failure with hypoxia). 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 
secondary diagnosis of J96.01- (Acute respiratory failure with hypoxia). Our physician reviewer found there 
was no evidence of arterial blood gas or oxygen saturation criteria to support this diagnosis. There was no 
documentation of change in cognition or mental status from baseline, accessory muscle use, or markedly low 
oxygenation after initial focused treatment in the emergency department. Additionally, records do not show any 
treatment rendered that would be consistent with acute respiratory failure. Therefore, the diagnosis of J96.01- 
(Acute respiratory failure with hypoxia) is not an appropriate secondary diagnosis.  
 
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 03, 2022, through January 08, 2022, and billed with 
diagnosis code J96.01.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says that the continuation 
of Keytruda is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
The file shows that the continuation of Keytruda therapy was requested. 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 Keytruda. Our physician reviewer found that the enrollee has cervical 
cancer. The FDA approved pembrolizumab to treat women with cervical cancer that has recurred or spread 
(metastasized) to other parts of the body and gotten worse during or after chemotherapy. The approval makes 
pembrolizumab the first immune checkpoint inhibitor approved to treat cervical cancer. Under the approval, 
patients' tumors must express PD-L1, as determined by an FDA-approved laboratory test. FDA simultaneously 
approved the PD-L1 IHC 22C3 pharmDx test (manufactured by Dako North America, Inc.), as a companion 
diagnostic test for women with cervical cancer. The accelerated approval was based on results from a single 
cohort of 98 women with cervical cancer who were enrolled in an ongoing phase 2 clinical trial of 
pembrolizumab for the treatment of several cancer types. The trial study states Pembrolizumab 200 mg was 
administered intravenously over 30 minutes every 3 weeks for up to 2 years. Treatment was discontinued upon 
disease progression, intolerable toxicity, physician decision, or patient withdrawal of consent. The study is 
ambiguous as it states 2 years for treatment. However, it also states that it is the physicians decision. The 
documentation does support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
pembrolizumab (Keytruda).  
 
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 pre-approve maxillofacial surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON maxillofacial surgery. You say that you understand that the 
requested facility is not an in-network hospital, but that this is the place that you have privileges at to treat your 
patients. The Plan denied your request. The Plan says there are network providers who can supply the enrollee 
with the care needed. 
 
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 
maxillofacial surgery 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 procedure code 71045-x-ray exam chest 1 view. 
 
You asked the Plan to pay for x-ray exam chest 1 view. You say that the service was rendered appropriately in 
response to the member's medical condition. The Plan denied your request. The Plan says the member was 
under hospice services on date of service January 03, 2022. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure code 71045-x-ray exam chest 1 view.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided November 12, 2022 to 
November 14, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this service was medically necessary. 
The Plan denied your request. The Plan says that the enrollee's needs could have been met at a lower level of 
care. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was admitted to the hospital for failure to thrive and abdominal pain. Imaging of 
the enrollee's chest and abdomen revealed an aneurysm. The admitting physician reasonable expected that 
inpatient care would 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided November 12, 2022 to November 14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are needed for the 
enrollee due to acute respiratory failure with hypoxia. The Plan denied your request. The Plan says when the 
enrollee is ready to leave the hospital services needed can safely be received in another setting, such as an 
Inpatient Rehabilitation Facility (IRF), a Skilled Nursing Facility (SNF) or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames and progressive lenses provided on March 16, 2022. 
 
  You asked the Plan to pay for frames and progressive lenses. You say that you had an eye examination and 
purchased your glasses from this provider. You also say this provider is part of the Plan network and this 
includes the purchase of eyeglasses through the provider. The Plan denied your request. The Plan says your 
benefit does not cover out-of-network vision care service/material. 
 
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 the services are obtained from a vendor inside the Plan vision 
vendor network. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine eye examinations and supplemental 
eyewear must be obtained from a provider in the Plan's vision vendor network. The Plan rules also say that 
services obtained from vendors outside this network are not covered. The record shows services were obtained 
from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of 
frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
frames and progressive lenses provided on March 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolia (J0897) provided on March 29, 2022. 
 
You asked the Plan to pay for the drug. You say that the service should be covered. The Plan denied your 
request. The Plan says additional information is needed. 
 
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 pay for the drug. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee has a reported diagnosis of osteoporosis. However, the provided record is 
insufficient to establish the medical necessity 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pay for Prolia (J0897) provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility (SNF) care provided to the 
enrollee on February 8, 2022. 
 
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 code 99310 remains denied as there is a more appropriate code to describe the services provided. 
 
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 99310 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided 
does not include sufficient documentation to validate billing CPT 99310 for the services provided on February 8, 2022; therefore, this service cannot be verified, and no additional payment is allowed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility (SNF) care provided to the enrollee on February 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient physician services billed for dates of service 
December 14, 2022, and December 15, 2022, with code 99233, and the services provided on December 16, 
2022, billed with code 99239. 
 
You asked the Plan to pay for the inpatient physician services. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says medical records for the dates at issue were not 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient physician services have 
been met. The file submitted does not include progress notes for the dates of service beyond December 13, 
2022. As such, the billed codes for the dates at issue cannot be verified. Therefore, we decided that the Plan 
does not have to pay for the inpatient physician services billed for dates of service December 14, 2022, and 
December 15, 2022, with code 99233, and the services provided on December 16, 2022, billed with code 
99239.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. You say the enrollee's needs cannot be adequately cared for at a skilled nursing facility 
or any other lower level of care. The Plan denied your request. The Plan says the LTACH admission you 
requested is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0425, A0427) provided on March 9, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that they were unable to review the appeal in the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has stated that the liability carrier is liable for this service. The provider 
has provided an EOB from the liability provider. The plan did not further articulate their denial. The plan did 
not cite the criteria or rule used to make their determination. Therefore, we decided that the Plan has to pay for 
ambulance services (A0425, A0427) provided on March 9, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital services provided 
on April 16, 2021, through June 3, 2021 and denied by the Plan with code G. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services have not been met. Specifically, the items and services at issue are 
considered routine. Payment for these services is included in the inpatient payment. Therefore, we decided that 
the Plan does not have to pay an additional amount for the inpatient hospital services provided on April 16, 
2021, through June 3, 2021 and denied by the Plan with code G.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; single view. 
 
You asked the Plan to pay for radiologic examination, chest; single view. You say that the procedure was 
rendered in the appropriate place of service. The Plan denied your request. The Plan says the incorrect place of 
service code was used. 
 
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 71045 is Radiologic examination, chest; single view. We 
find that CPT code 71045 is not supported in the medical record. Specifically based on the guidelines the 
member was registered as an inpatient of a hospital, therefore it would be inappropriate to report procedure 
code 71045 with an outpatient place of service 22. Based on this information, we decided that Medicare rules 
for coverage of radiologic examination, chest; single view have not been met. Therefore, we decided that the 
Plan does not have to pay for radiologic examination, chest; single view.