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 from July 23, 2022, to 
July 28, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
principal diagnosis code A41.9 was coded appropriately and the original DRG should remain unchanged. The 
Plan denied your request. The Plan says diagnosis code A41.9 is not supported, which resulted in a DRG 
change. 
 
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 with diagnosis code A41.9, defined as sepsis, unspecified 
organism. 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 diagnosis code A41.9 is not supported. Our physician reviewer 
found the enrollee had a Sequential Organ Failure System (SOFA) score of 0. The enrollee's condition did not 
fulfill the validated international consensus criteria for sepsis or a dysregulated immune response to infection.  
 
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 from July 23, 2022, to July 28, 2022, at the DRG originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions, alveoloplasty and debridement. 
 
You asked the Plan to pre-approve the dental services. You say that the tooth extractions are recommended in a 
hospital setting due to the enrollee's inability to tolerate a chairside procedure due to their autism and severe 
anxiety. The Plan denied your request. The Plan says the request is not covered under the enrollee's medical 
benefit and is also not a covered benefit under the supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The requested services are also not eligible for coverage under the 
medical benefit. Therefore, we decided that the Plan does not have to pre-approve extractions, alveoloplasty 
and debridement.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70546 billed for date of service February 14, 
2023. 
 You asked the Plan to pay for procedure code 70546. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70546 is bundled into payment for 
code 70553. 
 
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, we have confirmed that code 70546 is a column II code to column I code 70553. Code 70546 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70546 
billed for date of service February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this treatment is covered for lung cancer 
under Medicare, and that the enrollee is in a registry trial, and denial could hinder important evidence-based 
studies. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan. 
 The Plan follows Medicare rules. Medicare rules say that proton beam therapy may be covered under certain 
circumstances. 
 
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 Proton beam therapy. Our reviewer 
says that there is no plausible reason that proton therapy would be more beneficial than standard therapy for 
this particular enrollee. Our physician reviewer found that the enrollee does not meet the Group 1 or Group 2 
coverage conditions for proton beam therapy. A comparison plan is provided, though it is not evident if motion 
management was used in either or both plans. It is not evidence that proton therapy would reduce exposure to 
the central thoracic structures in a clinically meaningful way. There is no plausible reason that proton therapy 
would be more beneficial than standard therapy for this particular enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 3, 
2022. 
  You asked the Plan to pay for procedure code 99100. You say that the medical records should be reviewed, and 
the claim processed for payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, per day, for the evaluation 
and management of a patient (99309) provided on January 26, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you disagree with the denial of this 
claim and request reconsideration. The Plan denied your request. The Plan says there is no documentation of 
direct supervision by the physician as an integral part of the physicians personal in-office service required to 
bill Incident to Physicians Services. 
 
The Plan must follow Medicare rules. Medicare rules say that for hospital patients and for Skilled Nursing 
Facility (SNF) patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the 
services of physician-employed auxiliary personnel as services incident to physicians' services. 
 
We looked at your request, the file and Medicare rules. Based on this information, we have determined that the 
subsequent nursing facility care (99309) is not supported. Specifically, the records show that the services at 
issued were rendered by a Nurse Practitioner (NP) and billed by a physician. The record also shows that the 
service at issue was rendered in a Part A covered SNF stay. There is no Part B coverage of services of a NP as 
services indent to the physicians services. Additionally, the documentation does not support that these services 
were rendered under the direct supervision of the physician. Therefore, we decided that the Plan does not have 
to pay for subsequent nursing facility care, per day, for the evaluation and management of a patient (99309) 
provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
October 06, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was the result of 
previous procedures and should be covered. 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 physician/practitioner services.  
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
specialist 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. The record shows this claim was approved and you are responsible for the 
cost share amount. Therefore, we decided that the Plan does not have to waive the copayment for the specialist 
office visit provided on October 06, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the continued psychiatric hospital stay provided from December 13, 
2022, to January 4, 2023. 
 
You asked the Plan to pay for the continued psychiatric hospital stay. You say that the enrollee met mental 
health acuity during the denied portion of their stay. You also say that you would like payment to be remitted in 
full for the denied portion of the enrollee's stay. The Plan denied your request. The Plan says that the services 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued hospital stay. Our reviewer 
says that the psychiatric hospitalization was medically reasonable and necessary for the enrollee. Our physician 
reviewer found it was expected this enrollee would improve in a reasonable period of time beyond the dates in 
question, as although he was not showing any dangerousness to self or others, he did have auditory no visual 
hallucinations which required treatment. It did appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care. Our reviewer found that 
active treatment was taking place and the services were expected to improve the enrollees condition or were 
for the purpose of diagnosis. It did appear that active treatment was taking place, and the enrollee was found to 
have an individualized treatment plan in the record. The services were supervised and evaluated by a physician. 
Our physician reviewer also found that the Plans denial of inpatient psychiatric services is inappropriate. 
 
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 continued hospital stay have been met. Therefore, we decided that the Plan 
has to pay for the continued psychiatric hospital stay provided from December 13, 2022, to January 4, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 25, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.  
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823) and 
additional items and accessories (codes E1028, E0973 x2, and E2365).  
 You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that your current chair is not working at all. You also say that you need your chair fixed immediately 
so you can aid in your husbands care and gain your mobility. The Plan denied your request. The Plan says you 
do have a powered wheelchair that is in good condition and is safe for daily use. The Plan also says that this 
request is denied because it does not meet the rules for coverage. 
 
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. 
Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 group 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that this request is not medically reasonable and 
necessary. Our physician reviewer found you have pain and limited mobility. You currently have a functioning 
power wheelchair. Our reviewer found that you do not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. Our physician reviewer 
also found that you have 4 to 5 out of 5 strength in your upper extremities.  
 
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 group 2 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0823) and additional items and accessories (codes E1028, E0973 x2, and E2365).
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for myocardial infarction, urinary tract infection and cellulitis. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports 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. 
 
There is not a reasonable expectation that this 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found certainly using ultrasound on a daily basis is not unreasonable to offer but not necessary. The 
device itself is FDA approved for use with ultrasound though that in and of itself does not mean that daily 
imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280) and/or IGRT for a technology for which need has not been established by 
published data or supported by consensus guidelines is not necessary.  Billing for daily IGRT would not be 
furnished in accordance with accepted standards of medical practice.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT) (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy (99183, G0277) provided on 
February 1, 2023, to February 6, 2023. 
 
You asked the Plan to pay for hyperbaric oxygen therapy. You say that an authorization was obtained and 
approved for the diagnosis code entered. The Plan denied your request. The Plan says the billed service has 
been denied because it was reported with one or more diagnosis code pairs that are subject to an Excludes1 
note. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hyperbaric oxygen therapy have not been met. Specifically, this claim was billed with diagnosis 
codes I73.9 and I70.633. I79.9 includes an excludes1 note indicating that I79.9 and I70.633 cannot be billed 
together. Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen therapy (99183, 
G0277) provided on February 1, 2023, to February 6, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the swallowing and upper GI exams. We decided that the Plan does 
not have to pay for the remaining exams.  
 
You asked the Plan to pay for x-rays of the jaw, teeth, chest, cervical spine, swallowing function, and upper 
gastrointestinal (GI) tract provided on January 19, 2023.. You say that the services were necessary due to the 
enrollee's diagnosis of dysphasia. The Plan says that the services were not medically necessary. 
 
We decided that the Plan has to pay for the swallowing and upper GI exams.  
 
The Plan follows Medicare rules. Medicare rules say that coverage for barium swallow tests are covered for the 
conditions listed under 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 pay for the x-rays. Our reviewer says that the barium 
swallow and upper GI exams are medically necessary. Our physician reviewer found the barium swallow/upper 
GI (CPT 74240, 74230) meets the criteria listed under the Medicare rules section and were reasonable based 
upon the history of a cerebrovascular accident (CVA), malnutrition, and coughing, and should be reimbursed. 
 
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 x-rays have been met. Therefore, we decided that the Plan has to pay for the 
swallowing and upper GI exams.  
 
We also decided that the Plan does not have to pay for the remaining exams. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for barium swallow tests are covered for the 
conditions listed under 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 pay for the remaining exams. Our reviewer says that 
the remaining exams are not medically necessary. Our physician reviewer found the other exams (CPT 70100, 
70310 and 71045) did not meet the criteria listed under the Medicare rules section and were not necessary and 
should remain denied.  
 
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 remaining exams have not been met. Therefore, we decided that the Plan 
does not have to pay for the remaining exams. 
 
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.