Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 16, 2022.  
 
You asked the Plan to pay for the medical services. You say that these were emergency services and the Plan is 
required to make payment for them. The Plan denied your request. The Plan says Medicare health plans cannot 
pay for services from a provider ineligible for Medicare payment.   
The Plan must follow Medicare rules. Medicare rules say that generally freestanding EDs not affiliated with a 
hospital cannot be paid by Medicare. However, during the COVID pandemic, these providers were allowed to 
receive Medicare payment as a temporary hospital. 
 
We looked at the file and Medicare rules. The provider at issue is not shown to have enrolled in Medicare as a 
temporary hospital. 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 the medical services 
provided on July 16, 2022.
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 the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current setting.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 30, 2021, to 
August 5, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were billed correctly. The Plan denied your request. The Plan says the billed diagnosis of A41.51 
(sepsis due to Escherichia coli [E. coli]) is not supported in the medical record. Removal of this diagnosis 
resulted in a lower DRG being paid. 
 
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 a diagnosis of A41.51 (sepsis due to Escherichia 
coli [E. coli]). 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 diagnosis of A41.51 (sepsis due to Escherichia 
coli [E. coli]) is not supported by the medical record. Our physician reviewer found although the hospital coded 
for sepsis, the patient had no source of infection - the e coli in the urine very well represented asymptomatic 
bacturia. She had no urinary tract symptoms. She had evidence of celiac ischemia to explain her 
gastrointestinal symptoms. She did not have a Sequential Organ Failure Assessment (SOFA) score of 2 or 
more, so criteria for sepsis were not met.  
 
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 July 30, 2021, to August 5, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 1, 2022, to 
October 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that please see the attached notification for 
admission to the hospital. The Plan denied your request. The Plan says  the enrollee did not meet the inpatient 
admission criteria. 
 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 the review indicates that the enrollee was evaluated in the emergency department on 
October 1, 2022, after being involved in a motor vehicle accident (MVA). The MVA resulted in the car rolling 
onto the driver's side. The enrollee was amnestic about the event and was evaluated and found to have a tiny 
nondisplaced cervical vertebra fracture. Neurosurgery recommended cervical collar and outpatient follow up. 
The enrollee would have been discharged from the ED from a trauma standpoint but was admitted to telemetry 
for further evaluation for the syncope. The enrollee had a similar episode 11 years ago. The echocardiogram 
showed no acute abnormalities, and the enrollee had no orthostatic hypotension. The enrollee remained 
asymptomatic, was counseled on adequate hydration, and was discharged home the following day. The review 
has determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 1, 2022, to October 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on December 20, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this testing is covered and was medically 
necessary. The Plan denied your request. The Plan says the drug testing billed does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing drug testing, for the monitoring of 
patients on methadone maintenance and chronic pain patients with opioid dependence, providers must bill a 
primary diagnosis code of  Z79.899. The provider will then need to bill a diagnoses code that is covered under 
the Group 1 Codes section as the secondary diagnosis. 
 
In this case, you did appropriately bill diagnosis Z79.899 as the primary diagnosis.  However, the only 
secondary diagnosis you billed was R52. R52 is not listed as one of the covered diagnoses in the Group 1 
section of the above-referenced rule. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing provided on December 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for screening cytopathology testing provided on November 10, 2022. 
 
You asked the Plan to pay for screening cytopathology testing. You say that this is a prevent care exam that 
should be covered. The Plan denied your request. The Plan says that this test is covered once every 24 months 
and you previously received this test on November 1, 2021. 
 
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 claims that you received a covered Pap test on November 1, 2021; 
however, the Plan has not submitted any proof of coverage for a test performed on November 1, 2021, nor any 
other date within the 24 calendar months preceding November 10, 2022. Therefore, the Plan has not shown that 
its decision to deny payment for this test is correct or justified according to Medicare rules. Therefore, we 
decided that the Plan has to pay for screening cytopathology testing provided on November 10, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Euflexxa knee injections. 
 
You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee has had bilateral knee pain 
for over three years. You say that the enrollee reports that the pain worsens with activity. You say that the 
enrollee has tried and failed cortisone injections, Tylenol and physical therapy. You also say that you feel this 
is the best treatment for the enrollee. The Plan denied your request. The Plan says that the requested injections 
are not medically necessary. 
 
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 the Euflexxa injections. Our reviewer 
says that the Euflexxa injections are shown to be medically reasonable and necesary. Our physician reviewer 
found intra-articular injections with hyaluronic acid are recommended as a possible option for severe 
osteoarthritis for patients who have not responded adequately to recommended conservative treatments 
(exercise, non-steroid anti-inflammatory drugs, and/or Acetaminophen) or have had a failure of intra-articular 
glucocorticoid injections. The enrollee has had short-term relief with steroid injections but endorses up to six 
months of relief from prior viscosupplementation. The review has determined that the documentation supports 
that the Euflexxa is medically reasonable and necessary. The documentation supports that the Euflexxa is safe 
and effective for the enrollee's condition. 
 
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 Euflexxa injections have been met. Therefore, we decided that the Plan has 
to pre-approve Euflexxa knee injections.  
 
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 the enrollee does meet the guidelines for 
care at the LTACH. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 available at the LTACH that the enrollee requires that are not 
available at the healthcare setting being offered by the Plan. The Plan has approved ongoing care in the current 
acute care setting. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 24, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim was denied incorrectly. The Plan 
denied your request. The Plan says you billed this service with an incorrect pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. In this 
case, you billed this claim with diagnoses of E11.621 and E08.621. Code E08.621 is an Excludes1 code under 
code E11.621, so these two diagnoses cannot be billed together. 
 
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 24, 2023.
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 you are in need of the equipment offered in an IRF. 
The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. While you may need 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There 
is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
20, 2023. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the enrollee has 
made significant improvements in his medical condition, and continued SNF services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care after June 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 4, 2022, to June 
8, 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. The Plan denied your request. The Plan says secondary diagnosis code K85.90 is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code,  K85.90 , defined as 
acute pancreatitis without necrosis or infection, unspecified. 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 criteria 
for coverage have not been met. Our physician reviewer found the medical record does not include sufficient 
documentation to confirm a diagnosis of acute pancreatitis. The medical record does not include documentation 
of higher-than-normal levels of lipase. The normal range for amylase in a blood sample for an adult is 30 to 
110 units per liter (U/L). If amylase levels are higher than normal, a person may have one of many conditions. 
These include sudden swelling of the pancreas (acute pancreatitis). Amylase testing was not found in medical 
record. The computed tomography (CT) report documents, "I did independently review a CT of his abdomen 
and pelvis done in the emergency room without contrast, and my interpretation is no acute pelvic or abdominal 
findings. The medical record does not include consistent documentation of acute pancreatitis, throughout 
hospital stay. Therefore, this diagnosis code denied correctly, as 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 June 4, 2022, to June 8, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve collection and application of an autologous blood 
concentrate product (D7921 x 2) and sinus augmentation with bone or bone substitutes via a lateral open 
approach of the upper right and left quadrant (D7951).   
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve collection 
and application of an autologous blood concentrate product (D7921 x 2) and sinus augmentation with bone or 
bone substitutes via a lateral open approach of the upper right and left quadrant (D7951).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor control feature (L5856), stance phase 
control (L5828), stance flexion feature (L5845), dampening feature (L5848), multi-axial rotation unit (L5986) 
and shank foot system (L5987).  
 
You asked the Plan to pre-approve the prosthetic features. You say that these features are medically necessary. 
The Plan denied your request. The Plan says that the requested features are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that these prosthetic features are covered when the 
enrollee is at the necessary functional level. 
 
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 prosthetic features. Our reviewer 
says that the requested items are not medically necessary. Our physician reviewer found that the record does 
not support the enrollee is an advanced K3 ambulator who requires the additional features of the 
microprocessor system to regain or restore function. 
 
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 prosthetic features have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor control feature (L5856), stance phase control (L5828), stance 
flexion feature (L5845), dampening feature (L5848), multi-axial rotation unit (L5986) and shank foot system 
(L5987).