Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Oncotype DX Breast Recurrence Score (81519) provided June 23, 
2023. 
 
You asked the Plan to pay for the laboratory testing. You say that please immediately reprocess the claim as a 
covered service.  The Plan denied your request. The Plan says that the Oncotype Breast Recurrence Score test 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 laboratory testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found Oncotype DX Breast Recurrence Score testing was developed for patients with the following 
findings: estrogen-receptor positive, node-negative carcinoma of the breast, estrogen-receptor positive micro 
metastases of carcinoma of the breast, and estrogen-receptor positive breast carcinoma with 1-3 positive nodes. 
In this case, this is an estrogen-receptor positive and node-negative carcinoma of the breast. 
 
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 laboratory testing have been met. Therefore, we decided that the Plan has to 
pay for Oncotype DX Breast Recurrence Score (81519) provided June 23, 2023.  
 
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 for inpatient hospital services provided on March 26, 2023, to 
March 29, 2023, 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 
diagnosis code A41.9, (Sepsis, unspecified organism) was accurately reported and billed with the appropriate 
DRG The Plan denied your request. The Plan says the medical records did not have sufficient documentation to 
clinically validate the diagnosis of A41.9, (Sepsis, unspecified organism). 
 
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. 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 physician 
reviewer found that the patient did not meet Sepsis-3 criteria as there was insufficient evidence to support the 
patient experiencing organ failure directly related to a dysregulated response to systemic infection. Therefore, 
the diagnosis code A41.9 (Sepsis, unspecified organism) is not supported 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 March 26, 2023, to March 29, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
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 the enrollee needs aggressive inpatient rehabilitation 
to achieve highest level of function. The Plan denied your request. The Plan says the records show that it is not 
reasonable to expect the enrollee will be able to safely participate in, or fully benefit from, the intensity of 
services of an IRF. The Plan says services may be provided at a lower level of care.  
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the mattress, innerspring (E0271) purchased June 
30, 2023. 
 
You asked the Plan to reimburse you for the mattress. You say that you are appealing the denial of 
reimbursement. The Plan denied your request. The Plan says the item was purchased from a supplier who does 
not participate and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the mattress, innerspring 
(E0271) purchased June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided on July 18, 2023, to July 19, 
2023. 
 
You asked the Plan to pay for the inpatient care. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the inpatient care 
provided on July 18, 2023, to July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 3, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you disagree with the denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 27 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 17, 2023, to 
February 19, 2023, 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 the 
claim was billed at the correct DRG.  The Plan denied your request. The Plan says the DRG is not supported 
due to lack of support for code J96.90. 
 
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 J96.90, defined as 
respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia. 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 reported diagnosis code J96.90. Our physician 
reviewer found the patient was treated in the hospital for shortness of breath and splenic infarction. He has 
chronic obstructive pulmonary disease (COPD) on home oxygen (3 liters per minute via nasal cannula). 
Documentation describes the patient only requiring his baseline oxygen requirements throughout the hospital 
stay and did not require high flow oxygen, positive airway pressure, or ventilation supported, and was without 
acute respiratory distress after the initial oxygen support was applied. Therefore, this code, J96.90 - Respiratory 
failure, unspecified whether with hypoxia or hypercapnia, is not sufficiently supported in the documentation 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 February 17, 2023, to February 19, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hypoglossal Nerve Neurostimulator. 
 
You asked the Plan to pre-approve a Hypoglossal Nerve Neurostimulator. You say that the FDA recently 
expanded the criteria for body mass index for this device to 40, and it is medically necessary to treat the 
enrollee's sleep apnea. You say that without this device access to medical treatment is being prevented and 
there is a risk of other medical problems in the future. The Plan denied your request. The Plan says the 
requested Hypoglossal Nerve Neurostimulator does not meet the Medicare LCD coverage criteria. The enrollee 
has a body mass index of 36.0-36.9 and the criteria requires that the BMI be less than 35.  
 
The Plan follows Medicare rules. Medicare rules say that Hypoglossal Nerve Neurostimulator is covered when 
the criteria listed in the Medicare rules section of this decision are met. 
 
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 Hypoglossal Nerve Neurostimulator. 
Our reviewer says that the requested Hypoglossal Nerve Neurostimulator is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that based on the medical records 
provided, there is no documentation that the requested hypoglossal nerve neurostimulator meets the Medicare 
Local Coverage Determination (LCD) - Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep 
Apnea (L38387) coverage criteria. The provided records in this case document the patient's BMI was  36.05 kg/meter squared as of August 30, 2023, and the records from October 2, 2023 report the BMI as  
36.0-36.9. The Medicare LCD L38387 requires a BMI less than 35 kg/meter squared for coverage of the 
requested device.  
 
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 Hypoglossal Nerve Neurostimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Hypoglossal Nerve Neurostimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 9, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive testing is covered only under certain 
conditions listed in the rules section of this letter. 
 
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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
enrollee's diagnosis is medication management of long term (current) drug therapy. The enrollee is taking 
Morphine and Oxycodone. A definitive UDT panel for multiple drug classes was performed but does not show 
screening test results which are positive or inconsistent with prescription medications, dosing schedules, or 
history and expected results.  
 
The review has determined that the enrollee does not meet the LCD criteria for the definitive UDT for 22 or 
more drug classes. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided on March 27, 2023. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter are met. 
 
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 definitive UDT for 15-21 drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that the enrollee's 
diagnosis is medication management of long term (current) drug therapy. The medical record sent by the 
provider shows the member is taking Diazepam and Oxycodone. The presumptive screening test results are 
partially inconsistent with prescription medications, or history and expected results. Definitive confirmation 
testing was medically necessary for only 1 drug class: Opiates. The definitive UDT for 15-21 drug classes was 
not medically 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 the definitive UDT for 15-21 drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Cologuard colorectal cancer screening test (81528) 
 
You asked the Plan to pay for  Cologuard. You say that you were unaware of the Medicare age limits and 
criteria that the enrollee need to be asymptomatic. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee is 87 years old and is over the age limitation for 
coverage. Based on this information, we decided that Medicare rules for coverage of Colorguard have not been 
met. Therefore, we decided that the Plan does not have to pay for  the Cologuard colorectal cancer screening 
test (81528)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, P9603) provided on May 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 find that CPT codes  80053, & P9603 are not supported in the medical record. Specifically, the records do 
not include a physician order for a comprehensive metabolic panel. Additionally, the records do not note the 
travel allowance to support code P9603. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met.  
 
 Therefore, we decided that the Plan does not have to pay for lab services (80053, P9603) provided on May 1, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 16, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you do not feel 
responsible for the copayment because the quality of service received was very bad. 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 a $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency 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 copayment for an emergency room 
(ER) visit provided on March 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from March 28, 2022, to April 26, 
2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the documentation submitted did not contain the recertification OASIS 
that pertains to this billed episode of care.  
The Plan follows Medicare rules. Medicare rules state that payment for home health services is based on a 
case-mix methodology which is adjusted based in part on information from the OASIS assessment. 
 
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 home health care. Our reviewer says that this 
claim does not meet criteria for payment. Our physician reviewer found medical record includes nursing and 
therapy services were provided on dates of service billed, however medical record did not include OASIS (The 
instrument/data collection tool used to collect and report assessment data by home health agencies is called the 
Outcome and Assessment Information Set).  Oasis is standardized data set that measures quality and outcomes.  
It contains information regarding the patient such as the clinical condition, comorbidities, physical and mental 
state, functional status, living situation and health care needs.  Medicare requires home health agencies to 
collect and transmit OASIS. 
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pay for home health care provided from March 28, 2022, to April 26, 2022.