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

 
We decided that the Plan does not have to pay for lab services (U0004, U0005) provided on January 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is 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 CPT code. 
 
We find that CPT codes U0004, & U0005 are not supported in the medical record. Specifically, the enrollee 
was in a covered stay in a Skilled Nursing Facility on the date of service. This service is included in the Skilled 
Nursing Facility payment. 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 lab services (U0004, 
U0005) provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that that the ablation helps you with pain 
relief for four to six months sometimes longer. The Plan denied your request. The Plan says the genicular nerve 
block is not medically necessary.  
 
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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular 
nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically 
necessary for the treatment of chronic knee pain including osteoarthritis of the knee. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 sensor.  
You asked the Plan to pre-approve the FreeStyle Libre 14 sensor. You say that the medical records support the 
medical necessity for the CGM. The Plan denied your request. The Plan says the clinical information received 
shows no evidence of insulin use or a definition of hypoglycemia. 
 
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 14 sensor. Our 
reviewer says that the FreeStyle Libre 14 sensor is not medically necessary. Our physician reviewer found the 
records in this case do not document the enrollee is insulin treated or a history of problematic hypoglycemia. 
The criteria for CGM coverage 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 FreeStyle Libre 14 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre 14 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 29, 2023. 
 
You asked the Plan to pay for the billed services. You say that the billed codes are payable. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
 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 not show that the required unique 
identifier was reported. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed 
for date of service March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 2, 2022, 
to November 4, 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 coding 
acute kidney failure with tubular necrosis was correct and it is documented in the medical records. You say that 
the denial should be overturned, and payment approved at the originally billed DRG. The Plan denied your 
request. The Plan says diagnosis code N17.0 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 N17.0, defined as 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 reviewer says that the diagnosis is not supported. Our physician 
reviewer found that although the enrollee had evidence of a kidney injury, the clinical and laboratory evidence 
strongly supports a diagnosis of prerenal azotemia, not acute tubular necrosis.  
 
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 November 2, 2022, to November 4, 2022, at the DRG originally 
billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional transportation rides. 
 
You asked the Plan to pre-approve the additional transportation rides. You say that you do not feel that 24 trips 
are not enough. The Plan denied your request. The Plan says the benefits have been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional transportation rides.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on February 15, 2023, to February 
18, 2023, 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 this 
claim should be paid as is, because documentation supports code J96.21. The Plan denied your request. The 
Plan says that code J96.21 is not supported by the documentation.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.21, defined as acute and chronic respiratory 
failure with hypoxia. 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 J96.21 is supported in the documentation. Our 
physician reviewer found the enrollee has chronic respiratory failure from Chronic Obstructive Pulmonary 
Disease (COPD) requiring oxygen, and had worsening of respiratory status, so the enrollee meets criteria for 
acute on chronic respiratory failure, and thus code J96.21 is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on February 15, 2023, to February 18, 2023, at the Diagnosis Related Group (DRG) 
originally billed.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that you have shoulder pain and 
after x-rays and a magnetic resonance imaging (MRI) a tear in your rotator cuff was found. The Plan denied 
your request. The Plan says a platelet rich plasma is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are not covered.  
 
We looked at the file and Medicare rules. The record shows the injection was requested to manage a 
musculoskeletal injury. Based on this information, we decided that Medicare rules for coverage of a platelet 
rich plasma have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich 
plasma injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on April 
12, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that this service should be processed at 
an in-network benefit level. 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. Your 
contract with the Plan says that there is a $1,300 deductible which applies to out-of-network outpatient 
diagnostic tests and therapeutic services and supplies.  
 
The enrollee has been asked to pay $67.94 towards their deductible for the lab services. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $1,300 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 
This cost sharing is a contractual obligation that had not been met at the time the lab services was received on 
April 12, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory 
services provided on April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on January 16, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the item should be covered. The Plan 
denied your request. The Plan says this is not a covered item. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on January 16, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes Q0092 and R0070 billed for date of service February 
24, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was bedbound due to extreme pain. 
The Plan denied your request. The Plan says that the billed codes 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 CPT codes Q0092 and R0070 are supported in the medical record. Mobile imaging was provided 
in the home setting. The transportation component, R0070, is payable as the provider brought the equipment to 
the location. The claim shows that 2 units of code Q0092 was billed as 2 radiology procedures were provided. 
Carriers must pay a set-up component for each radiologic procedure. Based on this information, we decided 
that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has 
to pay for procedure codes Q0092 and R0070 billed for date of service February 24, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction. 
 
You asked the Plan to pre-approve a Positron emission tomography. The Plan denied your request. The Plan 
says determinations for PET CT scan is not covered for initial treatment strategy.  
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a Positron emission tomography. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found a PET scan is not 
reasonable at this time, with prostate cancer at high risk for metastatic disease with negative conventional 
imaging, physicians may obtain molecular imaging to evaluate for metastases. 
 
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 Positron emission tomography have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 billed for date of service May 20, 
2021. 
 
You asked the Plan to pay for the billed code. You say that the records support medical necessity. The Plan 
denied your request. The Plan says there is no separate payment.  
 
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 CPT code 64494 is a packaged service when provided in an ambulatory surgical center. No 
separate payment may be made for this service. Therefore, we decided that the Plan does not have to pay for 
procedure code 64494 billed for date of service May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
received. The Plan denied your request. The Plan says the record shows that the enrollee does not meet 
Medicare guidelines for services in an IRF.  
 
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 meet CMS coverage criteria for an IRF admission. The enrollee 
does not need specialized and intensive therapies consisting of at least 3 hours of therapy per day, at least 5 
days per week with a multidisciplinary approach in an IRF. The complexity of the enrollee's medical, 
rehabilitation, and nursing needs does not require an acute hospital inpatient rehabilitation stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs can be safely provided in an 
alternate and low intensity setting such as in an SNF or in-home with services.  
 
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 an IRF admission and services.
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 the enrollee currently meets LTACH 
admission criteria under CMS guidelines. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements and is not safe to leave the current hospital. 
 
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 current health care setting being offered by the health plan. 
 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visit, and the 
inpatient hospital stay provided from December 29, 2022, to December 31, 2022. 
 
You asked the Plan to waive the copayments for the emergency room visit, and the inpatient hospital stay. You 
say that you disagree with the copayments. 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 $90 
copayment per visit, for emergency care. Your contract with the Plan clearly says that you must pay a $250 
copayment per day, for days 1 to 7 per admission. 
 
You have been asked to pay a $90 copayment for the emergency room. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $250 copayment for day 1 of the inpatient 
hospital stay. This item/service falls within inpatient hospital care benefit category. You have been asked to 
pay a total of $340 ($90 copayment + $250 copayment = $340). 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 
copayments for the emergency room visit, and the inpatient hospital stay provided from December 29, 2022, to 
December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical extractions (D7210 x 2) provided on 
January 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware this provider was out-
of-network because this provider was referred to you by your dentist. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider.  
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the surgical extractions (D7210 x 2) 
provided on January 23, 2023.