Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 22, 2022, 
to October 21, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that the NOA was sent and 
acknowledged by the Plan on May 25, 2022. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 22, 2022, to 
October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from July 17, 2022, to 
August 10, 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 the 
documentation supports the DRG as billed, and the original determination should be overturned. The Plan 
denied your request. The Plan says diagnosis code A41.50 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 provided with principal diagnosis code A41.50, defined as gram-
negative sepsis, 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 documentation does not support 
principal diagnosis A41.50. Our physician reviewer found while the enrollee had a foot infection, there is no 
evidence that they had sepsis. There is no evidence of hypotension, hypoperfusion, or organ failure directly 
attributable to the infection. The enrollee was noted to be in no acute distress, not ill-appearing, not toxic-
appearing, not diaphoretic and hemodynamically stable.  
 
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 17, 2022, to August 10, 2022, at the DRG originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous electrocardiogram (EKG) recording services 
provided on February 16, 2023. 
 
You asked the Plan to pay for the continuous electrocardiogram (EKG) recording services. You say that the 
provider sent equipment before enrollee was advised of no prior authorization on file. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the continuous 
electrocardiogram (EKG) recording services provided on February 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 5, 2022, to July 
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 is 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 principal diagnosis code A41.9, described as Sepsis, 
unspecified organism, and secondary diagnosis code J96.22, described as Acute and chronic respiratory failure 
with hypercapnia. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found that the enrollee presented with a headache. He was found to have 
pneumonia. Mildly abnormal vital signs, present upon emergency department triage, corrected without 
intervention. There is no evidence of hypotension, hypoperfusion or organ failure. As such, a diagnosis of 
sepsis 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 July 5, 2022, to July 8, 2022, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305-PT billed for date of service February 
7, 2023. 
 
You asked the Plan to pay for procedure code 88305-PT. You say that this service was reported correctly. The 
Plan denied your request. The Plan says this service is not supported with the PT modifier as this code cannot 
be billed with this modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 procedure code 88305-PT. Our reviewer says that the use of 
the PT modifier is not supported with code 88305. Our reviewer found the medical records submitted include a 
pathology report for tissue from ascending colon. In this case, modifier PT is inappropriate, as this procedure is 
a laboratory procedure. The PT modifier is reported with a colorectal cancer screening test which led to a diagnostic procedure. Therefore, this procedure and modifier cannot be reported together. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88305-PT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88305-PT billed for date of service February 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629 x2). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barret's esophagus assay (0108U) provided 
on January 4, 2023.  
 
You asked the Plan to pay for the TissueCypher Barret's esophagus assay. You say that this test was ordered by 
the enrollee's treating physician with the intent to use test results to provide a risk score and risk class that are 
correlated with risk of progression to esophageal adenocarcinoma. The Plan denied your request. The Plan says 
the clinical value and effectiveness of TissueCypher Barrett's esophagus assay have not been demonstrated in 
the peer-reviewed literature 
 
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 pay for the TissueCypher Barret's esophagus assay. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the management strategy for individuals like the enrollee with 
non-dysplastic Barrett's esophagus (NDBE) with TissueCypher risk determination is yet undefined by specialty 
societies. Prospective studies in patients with NDBE are needed. Currently, biomarkers are not recommended 
for clinical use by most society guidelines. In this case, the medical necessity criteria for TissueCypher are not 
met. 
 
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 TissueCypher Barret's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barret's esophagus assay (0108U) provided on 
January 4, 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 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 is 
living in an assisted living with weakness and periodic falls. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 18, 2022, to 
June 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that your software vendor submitted 
an incorrect admission date. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported was not the first date in 
2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at issue 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from May 18, 2022, to June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E1002, E1028, E2361, and E2607) 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that you would like the original decision to be overturned. The Plan denied your request. The Plan 
says the enrollee does not have a qualifying diagnosis causing mobility limitation for which a K0856 group 3 
power wheelchair is medically needed. 
 
 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair with single power option (K0856) and additional items and accessories 
(codes E0955, E1002, E1028, E2361, and E2607)
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 7, 2023 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you do not 
know why the emergency medical services (EMS) came to your house and they did not do anything. You also 
say that you do not know why you are being billed if EMS did not take you anywhere or do anything. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 7, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 7, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015), or to pay more 
for a diagnostic eye examination (92004)  provided on March 31, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015) and to pay more for a diagnostic eye 
examination (92004). You say that you made a prior call to the Plan to check on the coverage of using this 
provider for your eye examination. You also say you were told that you would be covered for 80% for out-of-
network coverage. The Plan denied your request. The Plan says the provider is out of network, and the EOC 
states that routine eye services are not covered with an out-of-network provider. The Plan also paid the correct 
cost sharing amount for the diagnostic eye examination. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a determination of refractive state (92015) when provided by an in-network provider. 
The Plan also covers 20% of a medical eye examination (92004) from an out-of-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that that Original Medicare does not cover routine 
eye examinations  (eye refractions) for eyeglasses/contacts. The Plan contract also says that one routine vision 
(eye) examination and up to two refractions annually are not covered out-of-network. The record shows you 
received a determination of refractive state (92015) from an out-of-network provider. The Plan rules also say 
that there is a 20% coinsurance for each Medicare-covered visit for the diagnosis and treatment of diseases and 
injuries of the eye. The record shows that the Plan informed you there was a 20% coinsurance for a diagnostic 
eye examination. You were asked to pay $30.24, which is 20% of the allowed amount for the diagnostic eye 
examination (92004) ($151.21 x 20% = $30.24). Based on this information, we decided that the Plan's rules for 
coverage of a determination of refractive state (92015) have not been met. We have also decided that the Plan 
paid the correct cost sharing amount for a diagnostic eye examination (92004). Therefore, we decided that the 
Plan does not have to pay for a determination of refractive state (92015), or pay more for a diagnostic eye 
examination (92004)  provided on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for the Cxbladder Detect test (0012M) provided January 27, 
2023. 
 
You asked the Plan  to pay for the genetic testing. You say that the evidence supporting the use of Cxbladder 
Detect as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says the CX Bladder test remains unproven at this time. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have  to pay for 
the Cxbladder Detect test (0012M) provided January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
January 18, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have to 
pay for these services since they were necessary. 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 $200 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $200 copayment for the inpatient hospital stay. This item/service falls within the 
in-network inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. However, you only owe $48.14, which is less than the standard $200 
copayment. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital 
stay provided on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says there was no additional information received that supports any new injury 
or changes to the enrollee's progress.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the enrollee already had a CT scan that 
showed healing and good alignment. There is no documented change clinically. A repeat CT not needed. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the cervical spine.