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

 
We decided that the Plan has to pay for inpatient hospital services provided on January 14, 2023, to January 15, 
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 
metabolic encephalopathy is the correct secondary diagnosis. The Plan denied your request. The Plan says that 
the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported 
inpatient hospital services with the incorrect DRG. 
 
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, G93.41, defined as 
metabolic encephalopathy. 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 are 
supported by the medical records. Our physician reviewer found the enrollee had a change in mentation that 
prompted referral to the emergency room (ER). The enrollee had imaging changes and was treated for these 
changes. The changes did resolve promptly, but that does not mean the diagnosis was not present. The records 
support DRG 066. 
 
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 January 14, 2023, to January 15, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
13, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve RFA of the genicular nerves. You say that the previous genicular nerve 
RFA provided relief for 7 months. The Plan denied your request. The Plan says there are currently no clinical 
indications for this procedure. 
 
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 RFA of the genicular nerves. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered experimental therapy and is the subject of ongoing clinical 
trials. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the genicular nerves have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 9, 2022, to 
September 13, 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 acute 
kidney failure with tubular necrosis is the correct secondary diagnosis. The Plan denied your request. The Plan 
says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported 
inpatient hospital services with the incorrect DRG. 
 
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, N17.0, 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 services at issue in this case 
were not supported by the medical records. Our physician reviewer found records do not support a diagnosis of 
tubular necrosis. This enrollee did not have an increase in creatinine sufficient to make the acute kidney injury 
diagnosis. We do not believe that N17.0 is warranted. 
 
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 September 9, 2022, to September 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on March 29, 2023. 
 
You asked the Plan to pay for the crown. You say that the occlusal surface of tooth #19 had several craze lines 
(mini fractures) in the enamel extending to the mesial, distal, buccal, and lingual surfaces. You say that this 
tooth required a crown to restore it back to optimal function. The Plan denied your request. The Plan says the 
prognosis appears to be uncertain based on the information submitted and that the need for the service in 
dispute is not supported. 
 
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. The Plan covers crowns when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the criteria 
for coverage have not been met. Our physician reviewer found the x-ray provided shows severe bone loss 
around tooth #19, with root exposure, and furcation (area between the roots on a tooth) area. This tooth has a 
poor long-term prognosis due to the amount of bone loss. Based on the information provided, a crown is not 
medically reasonable in this situation as a crown on this tooth will likely fail due to the poor periodontal 
foundation around this tooth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) provided on March 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on February 9, 
2022. 
 
You asked the Plan to pay for an emergency department visit. You say that the claim was submitted well within 
the payer limits. The Plan denied your request. The Plan says the claim was denied due to not being filed until 
May 30, 2023, without good cause. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 The record shows that a claim for an emergency department visit was not filed until May 30, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit provided on February 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a compound drug infusion provided on June 2, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for a compound drug infusion. You say that the claim needs to be processed 
manually for payment to the provider. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services rendered. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a compound drug infusion provided on June 2, 
2023, by an out-of-network (OON) provider.
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 you cannot be safely discharged home. You need 
rehabilitation to help you regain your prior level of functioning and independence. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 you have stabilized medically and are ready for discharge from the hospital. You do 
not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can 
receive further rehab services at a lower level of care. Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition 
given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical 
problems. Your physical function is at or near your baseline and you can receive services at a lower level of 
care. Admission to a SNF for inpatient skilled rehab services is not 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 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: 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the requirements for approval of SNF care have not been met. 
 
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 the enrollee received oral and inhaled medications, had stable vital signs, and used 
oxygen via nasal cannula at baseline. The enrollee received physical therapy, speech therapy, occupational 
therapy. The enrollee was at a contact guard assist level with functional mobility, including gait to 100 feet. 
The enrollee required varying assist with activities of daily living. The enrollee had mild cognitive impairment. 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but 
they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service 
criteria for an inpatient basis in a SNF 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 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 waive the copayment for an injection and an ophthalmologist visit 
provided on July 6, 2023. 
 
You asked the Plan to waive the copayment for an injection and an ophthalmologist visit. You say that you do 
not agree with the copayment assessed. 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 Medicare Part B prescription drugs and a $35 copayment per visit to an ophthalmologist or 
optometrist for Medicare-covered vision care.  
 
You have been asked to pay $271.58 for an injection and an ophthalmologist visit. This total includes $236.58 
coinsurance, which is 20% of the allowed amount for a Medicare Part B drug injection ($1,182.92 allowed x 
20% = $236.58) and a $35 copayment for an ophthalmologist visit. The injection falls within the Medicare Part 
B prescription drugs benefit category. An ophthalmologist visit falls within the vision care benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an injection and an ophthalmologist visit provided on July 6, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation (RFA) services provided on May 9, 
2022. 
 
You asked the Plan to pay for the RFA services. You say that the records provided support the need for the 
services in dispute. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 RFA services. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic neck pain. He 
has tried topical medications, chiropractic care, physical therapy, home exercise, massage, acupuncture, and other alternative therapies. The enrollee has had 2 sets of diagnostic medial branch blocks at C4/C5, C5/C6, 
and C6/C7, each which produced 80% pain relief. Therefore, the RFA services in dispute are not considered 
medically reasonable and 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 RFA services have not been met. Therefore, we decided that the Plan does 
not have to pay for radiofrequency ablation (RFA) services provided on May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the enrollee urgently needs this device 
due to worsening heart failure. The Plan denied your request. The Plan says the service being requested is not 
covered. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 
4, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on April 4, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (procedure 99214) 
performed on June 23, 2023. 
 
You asked the Plan to pay for an office or other outpatient visit (procedure 99214). You say that procedure 
code 99214 is appropriate based on the level of services required. The Plan denied your request. The Plan says 
procedure code 99213 is more appropriate for the services rendered. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
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 an office or other outpatient visit (procedure 99214). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found that the documentation does not support this level of billing either by degree of complexity or by time. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office or other outpatient visit (procedure 99214) have not been met. 
Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit (procedure 
99214) performed on June 23, 2023.