Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on September 20, 2022, to 
September 23, 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 
medical records support the billing of secondary diagnosis code G93.41. The Plan denied your request. The 
Plan says that the medical records do not support the billing of secondary diagnosis code G93.41. 
 
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 G93.41. 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 medical records support the billing of secondary diagnosis code G93.41. Our physician reviewer found 
the medical records provided meet the definition of secondary diagnosis code G93.41. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on September 20, 2022, to September 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says these services can be provided in an alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies consisting of at least 3 hours of therapy 
per day at least 5 days per week with a multidisciplinary approach in an IRF. The documents do not support the 
necessity of an admission to an IRF. The complexity of the enrollee's medical, rehabilitation, and nursing needs 
does not require an acute hospital inpatient rehabilitation stay. The enrollee's rehabilitation needs can be met in 
an alternative, low intensity setting such as a skilled nursing 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64910 billed for date of service March 16, 
2023.   
You asked the Plan to pay for procedure code 64910. 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 64910 is 3. The MAI value for this code is 3. You billed 4 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 64910 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64910 billed for date of service March 16, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the air ambulance transportation provided on May 15, 2023.  
 
You asked the Plan to pay for the air ambulance transportation. You say that the enrollee was not an inpatient 
at the time of transport. She was discharged from one facility and transferred to another.  The Plan denied your 
request. The Plan says that the enrollee was inpatient as of May 14, 2023, meaning that separate payment 
cannot be made.  
 
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 not adequately supported that the enrollee was a registered 
inpatient at either facility at issue on the date of service on which the transportation took place. Though the 
inpatient claim from the destination facility includes May 14, 2023, the records provided by the transportation 
provider clearly document that the enrollee was still in the transferring facility's emergency department as of 
May 15, 2023. There is no evidence that the two facilities are affiliated with one another. As the Plan has not 
proven the enrollee's inpatient status with the receiving facility as of the time of this transport, we find that the 
denial of separate Part B payment is not supported.  Therefore, we decided that the Plan has to pay for the air 
ambulance transportation provided on May 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair replacement. 
 
You asked the Plan to pre-approve the replacement. You say that this is medically necessary. The Plan denied 
your request. The Plan says the notes do not show the current wheelchair cannot be fixed or that your condition 
has changed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the replacement. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited documentation regarding your level of mobility and function and why you 
require a power wheelchair for mobility versus requiring another assistive device, such as a cane, walker, or 
manual wheelchair. You have not had a power mobility evaluation and there is insufficient documentation as to 
the age of the current power wheelchair and why it does not work and cannot be repaired. versus requiring 
replacement. 
 
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 replacement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 28, 2023, billed with 
procedure code 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 2, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on March 28, 
2023, billed with procedure code 99233.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 19, 2022, to 
March 22, 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 I50.23 
is supported in the records, therefore, the claim should be paid at the DRG originally billed. The Plan denied 
your request. The Plan says I50.23 is not supported in the documentation. 
 
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 I50.23, defined as acute on 
chronic systolic (congestive) heart failure. 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 secondary diagnosis I50.23 is 
not supported in the documentation. Our physician reviewer found the provided records in this case do not 
document clinical signs, symptoms, radiologic or laboratory data, or treatment plans which support the 
diagnosis of acute on chronic systolic (congestive) heart failure. Records document no dyspnea or hypoxemia. 
There is no documentation of a third heart sound, no increased edema, no pulmonary edema on imaging, and 
no elevated pro-B type peptide levels on laboratory testing. Records document no need for diuretic therapy. An 
echocardiogram showed mildly decreased left ventricular systolic function but overall, no evidence of an acute 
exacerbation is 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 March 19, 2022, to March 22, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311) 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's right upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. There is not a medical need for the upgraded electronics. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electronic connection (E2311)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service February 25, 2023, 
to February 27, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 99233 is subsequent hospital inpatient or observation 
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, 50 minutes must be met or exceeded. 
 We find that CPT code 99233 is not supported in the medical record. Specifically, the documentation does not 
include the total time spent on this service. This means the total time required has not been met. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99233 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99233 for date of service February 
25, 2023, to February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eCoin neuromodulation system. 
 
You asked the Plan to pre-approve eCoin neuromodulation system. You say that the enrollee has tried and 
failed Toviaz, Vesicare, Myrbetriq and behavioral therapy. The Plan denied your request. The Plan says this is 
considered experimental and therefore is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve eCoin neuromodulation system. Our 
reviewer says that the requested eCoin neuromodulation system is not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is not enough research available to prove its long-
term safety and efficacy. As such, eCoin is considered to be an experimental treatment for the enrollee's 
condition. Therefore, the reviewer found that the eCoin neuromodulation system is not medically reasonable or 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 eCoin neuromodulation system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the eCoin neuromodulation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on October 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit". 
 
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 use of code 99233 is 
not supported by the records provided. Our reviewer found that the medical records submitted do not support a 
detailed interval history and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99233) provided on October 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory assist device (E0470) provided on April 17, 
2023. 
 
You asked the Plan to pay for respiratory assist device. You say that this item was medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 11, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a respiratory assist 
device (E0470) provided on April 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rotary wing air transport and rotary wing air mileage 
provided on March 26, 2023.  
You asked the Plan to pay for the rotary wing air transport and air mileage. You say that the flight and hospital 
records support the medical necessity for the air transport services.  The Plan denied your request. The Plan 
says the request for transport by air ambulance does not meet the policy used by the plan. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport and air mileage. 
Our reviewer says that the rotary wing air transport and air mileage was not medically necessary. Our physician 
reviewer found the enrollee presented to the emergency department after a reported fall and was found to have 
altered mental status, multiple fractures and abnormal labs. Encouragingly, no head injuries were identified. 
The lab abnormalities are consistent with a history of alcohol abuse. While further evaluation for the spinal 
fractures was warranted, it does not appear that the use of an air ambulance was medically necessary. An 
advanced life support ambulance or a community care ground transportation could have safely transported the 
enrollee, without an expected decline in their 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 rotary wing air transport and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for rotary wing air transport and rotary wing air mileage provided on 
March 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service April 21, 
2023.   
You asked the Plan to pay for procedure code 87798. 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 87798 is 13. The MAI value for this code is 3. You billed 19 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 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service April 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network nebulizer treatments provided 
from January 31, 2022, to May 31, 2023. 
 
You asked the Plan to waive the coinsurance for in-network nebulizer treatments. You say that this is a large 
amount to pay, and you are on a fixed income. 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 20% 
coinsurance for Medicare Part B prescription drugs and supplies.  
 
For the date range of this case: ($128.02 x 12 months = $1,536.24) + ($112.18 + $516.76 = $2,165.18) 
resulting in a $2,165.18 total charge for all the dates. You have been asked to pay a $2,165.18 total coinsurance for in-network nebulizer treatments. This 
item/service falls within the Medicare Part B prescription drugs and supplies 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 coinsurance for in-network nebulizer treatments provided from January 31, 2022, to 
May 31, 2023.