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 August 14, 2022, to 
September 2, 2022, 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 correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 E43, described as 
unspecified severe protein-calorie malnutrition. 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 documentation does not 
support the billed code. Our physician reviewer found that the enrollee reported eating well but is noted to have 
dementia. Her serum albumin was low, but she weighed 49 pounds more than her ideal body weight. While 
mild malnourishment/micronutrient deficiencies may have been present, the enrollee was not severely 
malnourished or calorie deficient. As such, the billing of E43 is not supported.  
 
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 August 14, 2022, to September 2, 2022, 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 alcohol and/or substance (other than tobacco) misuse 
structured assessment, and brief intervention (G0396) provided on September 12, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that substance abuse rehabilitation is not a benefit 
that Medicare covers. You also say this should be paid. The Plan denied your request. The Plan says payment 
cannot be to a provider that is not Medicare certified. 
 
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 pay for the alcohol and/or substance (other than 
tobacco) misuse structured assessment, and brief intervention (G0396) provided on September 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of chronic renal 
disease. She has not tried and failed the Plan's required drugs, Retacrit or Procrit. The records do not show that 
the required drugs would be contraindicated or less effective; therefore, Epogen is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epogen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you have scheduled knee surgery. 
The Plan denied your request. The Plan says this surgery can be done safely in an outpatient setting. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met. Our 
physician reviewer found you do not have serious medical problems that require monitoring in the hospital 
after your procedure. An admitting physician reasonably expected that your necessary hospital care would span 
at least 2 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 pre-approve acute inpatient level of care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 29, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that the provider visiting the nursing home had to 
see every patient that needed care. The Plan denied your request. The Plan says this was not authorized. 
 
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 nursing facility care provided on September 29, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a Zephyr valve placement (31647, 31651). 
 
You asked the Plan to pre-approve the Zephyr valve placement. You say that available documentation supports 
that the requested procedures are medically reasonable and necessary for this enrollee. Bronchoscopic 
placement of endobronchial valves via bronchoscopy can reduce lung volume in selected patients, and 
eliminate the need for surgery. The procedure is supported by the GOLD and National Institute for Health and 
Care Excellence (NICE) guidelines for selected patients with hyperinflation associated with severe 
emphysema. The Plan denied your request. The Plan says that this procedure is investigational and non-
covered. 
 
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 pre-approve the Zephyr valve placement. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case.   Our 
physician reviewer found the available documentation supports that the requested procedures are medically 
reasonable and necessary for this enrollee. Bronchoscopic placement of endobronchial valves via bronchoscopy 
can reduce lung volume in selected patients, and eliminate the need for surgery. The procedure is supported by 
the National Institute for Health and Care Excellence (NICE) guidelines for selected patients with 
hyperinflation associated with severe emphysema. 
 
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 Zephyr valve placement have been met. Therefore, we decided that the Plan 
has to pre-approve a Zephyr valve placement (31647, 31651).  
 
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 procedure code 99053 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99053 is considered bundled and not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 4, 2022, to 
April 2, 2022. 
 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 the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 4, 2022. The NOA was not received by the Plan until February 3, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 4, 2022, to April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 28470-54 for July 5, 
2022. 
 
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 the code was not billed with a required anatomical modifier. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical services billed with code 28470-54 for July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the office visits provided from May 26, 
2022, to June 2, 2022. 
 
You asked the Plan to pay an additional amount for the office visits provided from May 26, 2022, to June 2, 
2022. You say that you do not feel you should have to pay for these services. You also say that you did not see 
a specialist. 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 $35 copayment for specialist visits and a $5 copayment for professional services.  
 
You have been asked to pay a $35 copayment for the specialist office visit and a $5 copayment for the 
practitioner office visit. This item/service falls within the Physician/Practitioner services 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 pay an additional amount for the office visits provided from May 26, 2022, to June 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service December 13, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says the claim for the molecular pathology testing 
denoted by code 87631 did not include the required unique identifier. Procedure codes 94761 and 99072 are 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the unique identifier required 
for procedure code 87631 was reported. Additionally, we find that procedure code 94761 has a status indicator 
of T and procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure codes 94761 and 99072 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87631, 94761 and 99072 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service December 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 28, 2022, to 
May 12, 2022. 
 
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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal 
Information Processing Standards (FIPS) for home health claims. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct FIPS 
claim. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from April 
28, 2022, to May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99220 billed for date of service October 14, 2022. 
 
You asked the Plan to pay for code 99220. You say that this service was coded correctly. The Plan denied your 
request. The Plan says code 99220 is not supported in the medical record. The medical records don't support a 
comprehensive history and medical decision making of high complexity. 
 
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 99220 is  initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: a comprehensive history, a 
comprehensive examination, and medical decision making of high complexity. 
 
 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 code 99220. Our reviewer says that code 99220 is not 
supported in the medical record. Our reviewer found the member is a 68-year-old male with a medical history 
including hypertension, cardiac disease and alcohol use disorder who presented to the emergency room 
intoxicated and requesting detox. He was admitted for observational level of care. He was medically stable 
without any complications. The documentation does not indicate the encounter required medical decision 
making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99220 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99220 billed for date of service October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Comprehensive Complete Cancer panel (81162, 
81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81334, 81314, 81345, 81272) 
provided on August 22, 2022. 
 
You asked the Plan to pay for the CGx Comprehensive Complete Cancer panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this test should be billed with a single panel 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based on this information, we decided that Medicare rules for coverage of the CGx Comprehensive Complete Cancer 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the CGx Comprehensive 
Complete Cancer panel (81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 
81334, 81314, 81345, 81272) provided on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2022, billed with 
codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209,81314, 81334, 81345, 
81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 12, 2022, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81209,81314, 81334, 81345, 81272.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you cannot push a manual wheelchair. The 
Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
the requested power scooter is not medically necessary. Our physician reviewer found you indicate that you have a personal mobility deficit, but the documentation does not support that this impairs participation in 
mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in 
customary locations within the home. The documentation does not reveal that you are unable to ameliorate 
your mobility deficit with a walker or manual wheelchair or that you can safely operate and has maneuvering 
space in the home for the requested power scooter. Therefore, the reviewer found that the requested power 
scooter is 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says 8 additional physical therapy 
visits are not medically necessary.  
 
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 physical therapy visits. 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 that you have received an appropriate course of therapy and 
have shown a good response. You have an effective treatment program and may continue with a home exercise 
program. Therefore, continued input from a skilled therapist is 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.