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

 
We decided that the Plan does not have to pay for pathology services (88305) provided on May 1, 2023. 
 
You asked the Plan to pay for pathology services. You say that these services and conditions were reported 
appropriately. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that D12.4 has an Excludes1 note in relation to K63.5. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305) provided on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 22, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an out-of-network (OON) specialist. 
 
You asked the Plan to pre-approve the OON consultation. You say that the medical group does not have a 
network specialist that can take care of the enrollee's current eye condition. You say that they did not put the 
strabismus after cataract surgery as the diagnosis aside from double vision. You also say that this needs to be 
approved as soon as possible before the enrollee's eye condition worsens since they have been suffering for a 
while waiting for the medical group to authorize. The Plan denied your request. The Plan says the medically 
necessary care is available in network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON consultation. Our reviewer 
says that the request for an out-of-network (OON) consultation is not medically necessary. Our physician 
reviewer found the records do not indicate there is anything unique about the enrollee's condition that that 
would make it medically necessary for them to see the requested out-of-network provider. The reviewer found 
that the Plan has shown that they have in-network providers who meet the Standards of Care required for 
treatment of the enrollee's condition. Therefore, the reviewer found that the request for an out-of-network 
consultation 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 the OON consultation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a consultation with an out-of-network (OON) specialist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from February 24, 2023, 
to February 28, 2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
provider summitted supporting documentation for reconsideration. The Plan denied your request. The Plan says 
the DRG was updated. 
 
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 DRG 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented to the hospital with mental status changes, lethargy. The enrollee was started on 
fluids and antibiotics for dehydration and pneumonia. The workup also revealed no hypotension, mild acute 
kidney injury improved after fluids, mental status returned to baseline following initial fluids/treatment, no 
hypoxia, and platelets count was not low enough to meet Sepsis 3 criteria. There was no oliguria noted. The 
lower Glasgow Coma Scale (GCS) score was due to the enrollee's dehydration and baseline dementia. 
Therefore, the SOFA score was not 2+ and there was insufficient evidence to support the enrollee was 
experiencing a dysregulated response to systemic infection leading to organ failure as required to justify the 
codes, A41.9 and R65.20. Therefore, the DRG 193 is more appropriate for this admission based on the 
provided documentation.    
 
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 rendered from February 24, 2023, to February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on October 4, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
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 find that payment for CPT code 99291 is not supported in the medical record. Specifically, the medical 
record shows two dates of service, October 3, 2022, and October 4, 2022, on the report. As such, code 99291 
cannot be verified for the billed date of service. 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 
critical care services (99291) provided on October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a new amputee and requires an IRF 
level of care to build muscle before going home. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the requirements for an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall 
significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by the OT note from 11/1 and the PT note from 11/2/23).  Indeed, this enrollee's condition is in 
fact inherently complex, and there is every reason to expect that the enrollee will participate in and benefit from 
an IRF level of services to include at minimum PT, OT for pre-prosthetic rehab, physician oversight of wound 
care and polypharmacy, and case manager coordination of any additional services that might be needed to 
make a sustainable return, as well as avoid preventable readmissions to the acute hospital. The enrollee's needs 
cannot be met at a lower level of care. Therefore, the requested inpatient rehabilitation facility admission is 
approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 Freestyle Libre 2 sensor.

You asked the Plan to pre-approve the Freestyle Libre 2 sensor. You say that  the CGM is medically necessary and the submitted records support this request. The Plan denied your request. The Plan says the enrollee does not meet the requirements listed in Medicare's Glucose Monitors Local Coverage Determination (LCD) guideline (L33822). 

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre 2 sensor. Our reviewer says that this item is not medically necessary. Our physician reviewer found the record indicates that the enrollee has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has problematic hypoglycemia as defined by Medicare rules. The elements of the coverage criteria are not satisfied. 

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 Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan does not cover this requested device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (93702). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this technology is medically 
necessary to monitor the enrollee for lymphedema The Plan denied your request. The Plan says that 
bioimpedance spectroscopy is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that research indicates that bioimpedance spectroscopy is effective in identifying 
early lymphedema so that intervention can be started. Thus, in this case the requested service is considered 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy (93702).  
 
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 pay for a fluid circulating cold pad with pump (E0218) provided 
from April 13, 2023, to May 4, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump (E0218). You say that this item was 
medically necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. a fluid circulating cold pad with pump (E0218) is not covered by 
Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump (E0218) have not been met. Therefore, we decided that the 
Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided from April 13, 2023, to 
May 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health aide services.  
 
You asked the Plan to pre-approve the aide services. You say that you are undergoing treatments that are 
debilitating you. You also say that you need assistance to avoid falling. You also say that you do not have 
anyone to care for you. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the aide services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
documentation shows that you have had acute clinical status change. The reviewer also found there is no 
clinical care plan in which the skilled services of a home health aide would be required. Therefore, the reviewer 
found that the requested home health aide services are 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 the aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing (95937) provided on April 12, 2023. 
 
You asked the Plan to pay for the testing. 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 95937 is "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method". 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, it is inappropriate to bill 
code 95937 for train of four testing. Train of four testing is bundled into the procedure and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the train of four testing (95937) provided on 
April 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation facility stay you 
had from May 9, 2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation facility (IRF) stay. You say that you 
believe that this claim should be connected to another claim as one consecutive copayment. 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 $225 
copayment per day, for days 1 to 6, for each inpatient hospital stay. There is a $0 copayment for additional days 
after day 6. for inpatient hospital services.  
 You have been asked to pay a $1,350 copayment for an IRF stay ($225 per day x 6 days = $1,350). This cost 
sharing is per admission, regardless of the reason for the admission. 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 
copayment for the inpatient rehabilitation facility stay you had from May 9, 2023, to May 17, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service June 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a covered Medicare Benefit. The Plan 
denied your request. The Plan says that the rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. A review of the claim does show that the required unique identifier 
was reported. The test at issue is owned and operated by the billing provider. Research shows that the original 
molecular diagnostics company was acquired by the billing provider in 2022. Based on this information, we 
decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the 
lab testing billed for date of service June 12, 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: 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 the enrollee requires an IRF level of care. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission.  
 
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 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 multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a lower 
level of care.  
 
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.