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 on June 23, 2021, to 
June 27, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with this suggested change and contend that the diagnosis is supported by the documentation within 
the medical record and is a valid diagnosis. The Plan denied your request. The Plan says the secondary 
diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis (K85.90-acute pancreatitis 
without necrosis or infection, unspecified. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our physician reviewer found there was no clinical or 
laboratory evidence of a secondary diagnosis (K85.90-acute pancreatitis without necrosis or infection, 
unspecified)  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 23, 2021, to June 27, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that member's current medical condition 
requires an LTACH admission. The Plan denied your request. The Plan says the LTACH services requested do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation 
(76377-26-GC) provided from November 10, 2022. 
 
You asked the Plan to pay for the service. You say that the claim is billed correctly. The Plan denied your 
request. The Plan says the service is not supported by the code. 
 
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 the service. Our reviewer found the documentation submitted 
was reviewed and does meet criteria. After review of the medical record and Medicare guidelines in reference 
to 3D rendering, our coder was unable to verify. Per Health Plan, "The use of 3D-rendering with interpretation 
and reporting of computed tomography, magnetic resonance imaging, or other tomographic modality with 
image postprocessing is not covered separately by Medicare as it is contained in the authorized radiologic 
procedure. Radiologic techniques using 3D-rendering will be considered integral to the radiology services and 
not a separate service. Reimbursement will be based on the payment for the primary radiologic imaging 
service". Per guideline documents, "CPT codes 76376 and 76377 are allowed only when billed in conjunction 
with another computed tomography, magnetic resonance imaging or other tomographic modality procedure 
codes". Therefore, our coder unable to verify an unbundled procedure 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance 
imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; 
requiring image postprocessing on an independent workstation (76377-26-GC) provided from November 10, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 3, 2022, to July 
6, 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 
services are supported. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9- 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 physician reviewer found the enrollee presented with weakness and malaise. The enrollee was found to 
have a complicated urinary tract infection (UTI). The enrollee's vital signs were stable. There is no evidence of 
organ failure. The enrollee responded to fluids and antibiotics and was discharged promptly. The billing of 
A41.9 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 3, 2022, to July 6, 2022, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on July 25, 2022, 
billed with codes 63056, 63057, 22216, and 20937. 
 You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied 
your request. The Plan says the denied codes 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 63056 is transpedicular approach with decompression of 
spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including 
transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc). Code 22216 is 
defined as osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional 
vertebral segment (List separately in addition to primary procedure). Code 20937 is defined as autograft for 
spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List 
separately in addition to code for primary procedure). 
 
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 as billed. Our reviewer says that the codes 
63056, 22216, and 20937 are not supported by the records. Our reviewer found for code 63056, this service is 
documented when the physician approaches a herniated disc through the pedicle on the side of the disc's bulge, 
with additional exposure being made by removing the lamina and facet joint. The operative report does not 
include this description.  
 
For code 22216, the report does not include sufficient documentation to confirm this procedure has been 
performed. The report documents, "Then, the posterior common osteotomies were performed at bilateral L3-L4 
with facetectomy and laminectomy for correction of sagittal balance, restoration of lordosis and correction of 
spinal deformity". In this case, there is insufficient description of the procedure, and therefore, the code cannot 
be verified. 
 
There is also insufficient description of autograft harvesting to support code 20937. 
 
In addition to the codes reviewed by our coder, we find that code 63057 is a Column 2 code in relation to 
Column 1 code 22633. A modifier was not appended to 63057 to bypass the edit. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical assistant services provided on July 25, 2022, billed with codes 63056, 
63057, 22216, and 20937.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography (75716 and 75774) provided on November 
11, 2022. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records submitted do not support procedure codes 75716 and 75774. 
 
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 services. Our physician reviewer found 
for code 75716, the documentation submitted was reviewed and does not meet criteria. The provider documents 
in the procedure report, "Patient has no contrasted or invasive study for this clinical picture, so a diagnostic angiogram is performed today on the same day as intervention". In this case, there is insufficient 
documentation to confirm criteria for a diagnostic angiogram and the intervention procedure performed. For 
code 75774, the documentation submitted was reviewed and does not meet criteria. The provider documents in 
the procedure report, "Patient has no contrasted or invasive study for this clinical picture, so a diagnostic 
angiogram is performed today on the same day as intervention". In this case, there is insufficient 
documentation to confirm criteria for a diagnostic angiogram and the intervention procedure performed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the angiography (75716 and 75774) provided on November 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the enrollee's records show that they can complete daily tasks as well as 
they could before they were admitted into the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
requires skilled nursing services. The enrollee does require skilled therapy services. There is no documentation 
that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. Records 
support that services in the home with home health care or in a long-term care facility on a part time basis are 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on November 15, 2022. 
 You asked the Plan to pay for the EM services. You say that this was a medically necessary service that should 
be reimbursed. The Plan denied your request. The Plan says this was not billed with an appropriate primary 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes that are identified as 
manifestation codes should not be sequenced before the code for the underlying etiology. 
 
We looked at the file and Medicare rules. The claim was billed with primary diagnosis code F05. This code has 
a "code first" note that indicates to sequence the underlying psychological condition first. Based on this 
information, we decided that Medicare rules for coverage of the EM services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided 
on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 28272 billed for date of service August 11, 2022. 
 
You asked the Plan to pay for code 28272. You say that the medical records support the billing of procedure 
code 28272. The Plan denied your request. The Plan says the medical records do not support the billing of 
procedure code 28272. 
 
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 28272 is Capsulotomy; interphalangeal joint, each joint 
(separate procedure). 
 
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 code 28272. Our reviewer says that code 28272 is not 
supported by the medical record. Our reviewer found the records indicate that tenotomy surgery was performed. CPT 28272 is not the correct code as it is for joint capsulotomy, which is a different procedure 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 28272 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 28272 billed for date of service August 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 22, 2021, to July 
25, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services are supported. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9- 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 physician reviewer found the enrollee was admitted with chest pain, a wet cough, shortness of breath and 
dyspnea on exertion. The enrollee was treated for possible pneumonia, but ultimately determined to have 
chronic obstructive pulmonary disease (COPD)/chronic heart failure (CHF). There is no evidence of an 
infection resulting in systemic illness or organ failure. As such, the billing of A41.9 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 22, 2021, to July 25, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 8, 2022, to 
January 11, 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 
services are supported. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.9- Acute kidney 
failure, 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 physician reviewer found the enrollee was treated for enteritis 
resulting in mild dehydration. There is no evidence that the enrollee had overt renal failure. As such, the billing 
of N17.9 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 January 8, 2022, to January 11, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from February 19, 2020, through 
March 12, 2020. 
 
You asked the Plan to pay for the inpatient care. You say that it is felt that the full payment should be made on 
this claim. The Plan denied your request. The Plan says that despite requests for the itemized bill, the Plan only 
received a copy that is missing the last five pages. 
 
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 file submitted did not include sufficient documentation to support the Plan's 
denial rationale. It is indicated that an incomplete itemized bill was submitted by the provider during the appeal 
process. The Plan did not include a copy of the purportedly incomplete bill. In addition, the medical records 
included do not appear to be complete. The page markers indicate that the file should be 1760 pages, but only 
up to page 200 was submitted in the file. Due to these substantial omissions, we find that the denial of payment 
is not supported. Therefore, we decided that the Plan has to pay for the inpatient hospital care provided from 
February 19, 2020, through March 12, 2020.  
 
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 pay for inpatient hospital services provided on October 13, 2022, to 
October 15, 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 
services are supported. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N17.0- Acute kidney failure with tubular necrosis. 
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 physician reviewer found the enrollee presented with abdominal pain. The enrollee was 
found to have a gallstone with mild obstruction, in the setting of chronic kidney disease. The enrollees 
gallbladder was surgically removed, and she was discharged the following day. There is no evidence that the 
enrollee was evaluated for or treated for acute renal issues. There is no evidence that the enrollee had acute 
renal failure or acute tubular necrosis (ATN). As such, the billing of N17.0 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 October 13, 2022, to October 15, 2022, at the Diagnosis Related 
Group (DRG) originally billed.