Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found that the documentation indicates the 
prescribed medication stelara is a new and ongoing therapy with an alternative medication is not being 
disrupted. However, there is no documentation to support the enrollee has had an adequate trial of the required 
step therapy medication to warrant treatment with the requested medication. Additionally, there is no 
documentation to indicate the enrollee would be adversely affected by treatment with the on-formulary drug 
alternatives and progressing to other drug therapies only as 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 27, 2022, to 
February 1, 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 these 
services/diagnoses were reported accurately and are supported in the medical record. The Plan denied your 
request. The Plan says the documentation provided supports that anemia (D50) is the primary diagnosis with 
other gastritis with bleeding (K29.61) as a secondary diagnosis. This means the DRG is supported as 377 rather 
than 811. 
 
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 other gastritis with bleeding (K29.61) as the 
principal diagnosis. 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 although this diagnosis is supported in the medical 
record, it is not supported as the primary diagnosis in this case. Our physician reviewer found according to 
Medicare, the circumstances of inpatient admission always govern the selection of principal diagnosis. The 
principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning 
the admission of the patient to the hospital for care. The definition for other diagnoses is interpreted as 
additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; 
or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. In 
this case, the documentation does not consistently and completely support the assigned principal diagnosis code 
with DRG. The replacement of DRG is upheld as it is supported by the medical documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 27, 2022, to February 1, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service November 15, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you have provided the operative report to 
support payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service November 15, 2022, 
billed with code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the DecisionDx-SCC test (0315U) provided November 11, 
2022. 
 
You asked the Plan to pay for  genetic testing. You say that the DecisionDx-SCC test is medically necessary 
and requesting to be reprocessed and paid. The Plan denied your request. The Plan says the DecisionDx-SCC 
test 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 pay for genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the DecisionDx-SCC test is not medically necessary. It is not a standard 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for  the DecisionDx-SCC test (0315U) provided November 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-transport ambulance services provided on December 
26, 2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that the claim you filed is validly 
billed. The Plan denied your request. The Plan says you billed these services with an incorrect modifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the non-transport ambulance services provided on 
December 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network vascular surgeon. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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. The file shows that the enrollee will be 
moving the Plans service area on August 19, 2023. 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 a referral to an 
out-of-network vascular surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service June 20, 
2022.  
 
You asked the Plan to pay for procedure code 95861. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95861 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95861 billed for date of service June 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 7, 2023, billed with 
codes 81291, 81401, 81335, 81227, 81225, 81230, 81328, 81231, 81355, 81232, 81226, 81408, 81240, and 
81241. 
  
 
You asked the Plan to pay for the genetic testing billed. You say that this testing is medically necessary.  The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 7, 2023, billed with codes 81291, 81401, 81335, 81227, 81225, 81230, 81328, 81231, 81355, 81232, 
81226, 81408, 81240, and 81241.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (GHP) provided on February 7, 
2023, billed with code 80050. 
 
You asked the Plan to pay for the GHP as billed. You say that you feel that this testing should be covered as 
you were not told it was not covered.  The Plan denied your request. The Plan says this test was correctly 
denied.  
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
The provider requested payment for services billed under code 80050. Medicare does not cover or pay for 
services billed under this code. The provider should resubmit these tests with covered codes. Therefore, we 
decided that the Plan does not have to pay for the general health panel (GHP) provided on February 7, 2023, 
billed with code 80050.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 19, 2022, 
to November 23, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 J96.01, described as 
Acute 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 documentation does not support 
the billed code. Our physician reviewer found that the enrollee presented with a subacute illness. She was 
found to have bronchospasm and an elevated troponin. She responded to steroids and nebulizers. She did not 
require ventilatory support. The enrollees symptoms can be explained by the diagnosis of Chronic obstructive 
pulmonary disease exacerbation. There is no evidence of acute respiratory failure. As such, the billing of 
J96.01 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 November 19, 2022, to November 23, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial hospitalization treatment. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says after completion of inpatient treatment, with resolution of risk symptoms, the enrollee 
can be safely managed at the Intensive Outpatient Protocol (IOP) level. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is not showing any dangerousness to self or others and has not been exhibiting severe 
psychological or psychiatric impairment requiring this level of care. The enrollee was not showing any 
perceptual disturbance, psychosis or aggressive behaviors. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the partial hospitalization level of care rather than a lower level of care as 
he did not have any suicidal or homicidal thoughts or behavioral disturbance and his symptomatology could be 
treated at a lower level of care. The health plans denial of continued partial hospitalization treatment for the 
dates in question appears appropriate. This enrollee did not appear to require partial hospitalization treatment. 
 
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 pre-approve partial hospitalization treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the appropriate level of 
care for the enrollee. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says admission to an LTACH is not medically necessary.  
 
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 that all medically necessary care is being provided in the current acute care setting.  
 
 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 Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 5, 2022, to July 
8, 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 
diagnoses and services on this claim were reported appropriately. The Plan denied your request. The Plan says 
this diagnosis is not supported in the medical record. 
 
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 acute kidney failure, unspecified (17.9). 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 this diagnosis is not supported in the medical record. Our physician reviewer 
found while admitted, the enrollee had abdominal x-rays, computed tomography (CT) scan of the 
abdomen/pelvis and a Gastrograffan study, all of which did not demonstrate a small bowel obstruction. There 
was no nausea or vomiting and the enrollee tolerated an oral diet and had multiple bowel movements. The 
records do not support a diagnosis of acute kidney failure, unspecified (17.9).  
 
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 5, 2022, to July 8, 2022, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test provided on January 18, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that the DecisionDx-SCC test is medically 
necessary. The Plan denied your request. The Plan says the DecisionDx-SCC test 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 pay for the DecisionDx-SCC test. Our reviewer says 
that the requested DecisionDx-SCC test is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has squamous cell carcinoma of the skin/face. However, the 
DecisionDx-SCC test does not meet Medicare coverage criteria as there is insufficient current high-quality 
literature currently available that shows it leads to an improved overall clinical outcome compared to standard 
testing options for this enrollees condition.   
 
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 DecisionDx-SCC test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SCC test provided on January 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from November 2, 2022, to 
November 4, 2022. 
 
You asked the Plan to pay for the hospital services. You say that these services were provided in good faith and 
this claim should be paid. The Plan denied your request. The Plan says you billed this claim with an incorrect 
diagnosis code, so the claim cannot be prices. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill accurate diagnosis codes.  
In this case, you billed these hospital services with a diagnosis code of O99.43.  The definition of this diagnosis 
code is "Diseases of the circulatory system complicating the puerperium, for patients aged 12-55."  However, 
the records show that the patient was 57 years old at the time of the services in dispute.  As a result, a different 
diagnosis should have been billed on the claim in order to calculate the payable rate for these services. 
 
Therefore, we decided that the Plan does not have to pay for hospital services provided from November 2, 
2022, to November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service January 5, 2023. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that you should be paid for 
more than just the professional component for these codes.  The Plan denied your request. The Plan says this 
code is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service January 5, 2023.