Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code G92.8 
rendered from November 15, 2021, to November 19, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment Clinical 
Validation Audit was performed to ensure that the diagnosis codes on the claim supported clinically. 
 
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 535. 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's workup and monitoring revealed no acute findings on imaging, unremarkable labs. 
Medication side effects were suspected and Ultram, Xanax, Klonopin, Buspar, Trazadone, Zyprexa, and Atarax 
were held. Mental status promptly improved following the medication changes. However, the enrollee was 
reported to still have episodes of confusion and agitation at night which was suspected to be baseline dementia 
in the provided documentation. Polypharmacy with many central nervous system (CNS) depressants over a 
baseline dementia was likely causing her symptoms. There was insufficient evidence to support 
encephalopathy. A more appropriate diagnosis code for this clinical situation would be T50.995A (adverse 
effect of drugs). Therefore, the documentation supports DRG of 536 for this admission.  
 
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 billed with diagnosis code G92.8 rendered from November 15, 2021, to 
November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated 
(36475). 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. 
 
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 endovenous ablation therapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, extremity, inclusive of all 
imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated (36475).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6220 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for procedure code A6220. The Plan denied your request. The Plan says procedure 
code A6220 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A6220 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6220 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A6220 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6220 billed for date of service January 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) additional home physical therapy (PT) visits.  
You asked the Plan to pre-approve home health services. You say that you cannot get in the house at all by 
yourself. You cannot get up the steps. When you were getting physical therapy, you were improving, but you 
could not do it alone. You feel continued physical therapy will help. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you were 
admitted to the hospital on May 16, 2023, for CHF, weakness, hypomagnesemia. You were admitted to 
subacute rehab on May 17, 2023. You were discharged home with home care physical therapy (PT), 
occupational therapy (OT), and skilled nursing (SN). The remaining 3 home health PT visits are not medically 
necessary as skilled therapy services are not required to effectively provide treatment, care, and/or services in 
order to improve your level of function, or to establish/perform a maintenance program to maintain your level 
of function and/or prevent deterioration. You have had instruction on a home physical therapy program. You 
were approved one visit for stair training and safety. The documentation does not support that you require 
ongoing formal skilled PT beyond what was approved. The criteria for home health physical therapy have not 
been met per Medicare Benefit Policy Manual, Chapter 7. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve three (3) additional home physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services billed with diagnosis code 
G92.9 rendered from October 6, 2021, to October 7, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim were supported clinically. 
 
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 896. 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 alcohol withdrawal symptoms. He was noted to be alert and 
oriented and was diagnosed with delirium. The workup did not reveal another cause including any toxic 
exposure to explain his mental status changes. The code, G92.9 - unspecified toxic encephalopathy is not 
supported in the documentation, and the most appropriate primary diagnosis for this admission would be 
alcohol dependence with withdrawal delirium (F10.231). Therefore, the most appropriate DRG would be 897.  
 
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 acute inpatient hospital services billed with diagnosis code G92.9 rendered from October 6, 2021, to 
October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services in order to return 
home independent. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 6, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. 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 providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient. 
 
We find that CPT code 99223 was billed with 21, an inpatient place of service code. The enrollees claim 
information shows that the enrollee was in outpatient observation at the time the services at issue were 
provided. 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 procedure code 99223 billed for 
date of service February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 provided on January 13, 2023, and 
January 14, 2023. 
 
You asked the Plan to pay for procedure code 93042. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
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 93042 is Rhythm ECG, 1-3 leads; interpretation and 
report only 
 
We find that CPT code 93042 is not supported in the medical record. Specifically, the records provided do not 
describe that an ECG was performed on January 13, 2023, and January 14, 2023. Based on this information, we 
decided that Medicare rules for coverage of procedure code 93042 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 93042 provided on January 13, 2023, and January 14, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found the provided records document that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel positive 
airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. The 
LCD requires: "There must be enough detailed information in the medical record to justify the treatment 
selected." Provided records in this case do not provide adequate detailed information to meet Medicare criteria 
for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 more home skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that you need the nursing care and are not 
able to leave the house. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that you require additional skilled nursing services to provide treatment that is 
medically necessary. You do not require additional skilled nursing services to effectively provide treatment, 
care, and/or services in order to improve your condition, perform a maintenance program to maintain your 
condition, and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 more home skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the drug injections provided on February 
15, 2023. 
 
You asked the Plan to reduce the coinsurance for the drug injections. You say that you were overcharged for 
this service. 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 20% 
coinsurance for in-network Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the drug injections. This item/service falls within the Medicare Part B drugs 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. Therefore, we decided that the Plan does not have to reduce the coinsurance for the drug 
injections provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0241U-QW provided on 
December 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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. 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 lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 0241U-
QW provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious disease (viral respiratory tract infection), 
pathogen-specific RNA, 4 targets, upper respiratory specimen, each pathogen reported as detected or not 
detected (0241U) provided on January 11, 2023. 
 You asked the Plan to pay for laboratory services. You say that you have submitted requested medical records 
as supporting documentation for the charge on this claim. 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. 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 laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for infectious disease (viral 
respiratory tract infection), pathogen-specific RNA, 4 targets, upper respiratory specimen, each pathogen 
reported as detected or not detected (0241U) provided on January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left 
atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation (33340). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this request is not medically necessary because the documentation does not 
support a formal shared decision-making interaction with an independent non-interventional physician 
supporting that this procedure 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 the service. Our physician reviewer 
found LAAC has been recommended by interventional cardiologist for cited reason of fall risk. However, 
records do not document that a formal decision-making interaction with a non-interventional physician was 
performed. As such, guidelines would not support implantation of a LAAC in this setting. In summary, LAAC 
placement would not be considered reasonable or medically necessary in this enrollee's 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous transcatheter closure of the left atrial appendage with endocardial 
implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial 
appendage angiography, when performed, and radiological supervision and interpretation (33340).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99203, 99213) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99203, 99213) to be provided by an out-of-network (OON) provider.