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

 
We decided that the Plan does not have to pre-approve Phesgo. 
 
You asked the Plan to pre-approve Phesgo. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Phesgo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Phesgo is not FDA-
approved for the enrollees diagnosis. The drug is not being given with a taxane. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Phesgo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Phesgo.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare guidance says the provider must attempt to consult the attending or primary care 
physician about the services furnished. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the disposable diapers purchased 
from September 20, 2022, to December 27, 2022. 
 
You asked the Plan to increase the reimbursement for the disposable diapers. You say that you should have 
been reimbursed a total of $453.05. The Plan denied your request. The Plan says that you have been reimbursed 
the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
 The record shows you were reimbursed the full Medicare allowed amount for the disposable diapers purchased 
from September 20, 2022, to December 27, 2022. You were reimbursed a total of $63.28. This item/service 
falls within the durable medical equipment benefit category. This means that you have been reimbursed the 
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to 
increase the reimbursement for the disposable diapers purchased from September 20, 2022, to December 27, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code G93.41 
rendered from September 22, 2021, to September 27, 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 there was no new documentation or clinical 
evidence presented to support an overturn of the initial audit findings. 
 
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 diagnosis code G93.41. 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 condition did not meet criteria for acute change and evidence of global 
impairment. Metabolic encephalopathy is a global condition. The plan has appropriately denied the code.  
 
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 G93.41 rendered from September 22, 2021, to 
September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
13, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the short-latency somatosensory evoked potential study, stimulation of 
any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head (95927) 
provided on April 27, 2021. 
 
You asked the Plan to pay for the service. You say that the medical records support the billing of code 95927.  
The Plan denied your request. The Plan says that the medical records do not support the billing of code 95927.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We asked our coder to carefully review the case 
file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 
the service. Our reviewer found the submitted medical records did include documentation to support that short-
latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording 
from the central nervous system; in the trunk or head was performed. The review has determined that the 
medical records did support the billing of code 95927. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pay for 
the short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in the trunk or head (95927) provided on April 27, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from April 12, 2021, to April 27, 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 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 diagnosis code A41.9. 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 the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of A41.9 (Sepsis, unspecified organism). In this case, the documentation 
does not consistently and completely support the assigned secondary diagnosis code. The decision to remove 
the secondary diagnosis code and adjust the DRG is upheld.  
 
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 A41.9 rendered from April 12, 2021, to April 27, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 19, 2022, to 
May 20, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was 
provided in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.  Our 
physician reviewer found that this hospitalization does not qualify for inpatient payment under the two-
midnight rule. At the time of admission, it was not reasonable to expect that two midnights in the hospital 
would be required. The enrollee presented to the emergency department with abdominal pain. The enrollee was 
found to have gallstones, but no evidence of gallbladder infection or obstruction. There were no immediate 
plans for surgery and the enrollee was cared for by the medical service. The following day, she underwent 
elective gallbladder removal and was subsequently discharged. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered from May 19, 2022, to May 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from June 30, 2022, to July 5, 2022. 
 
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 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 diagnosis code A41.9. 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 the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of A41.9 (Sepsis, unspecified organism). In this case, the documentation 
does not consistently and completely support the assigned secondary diagnosis code. The decision to remove 
the secondary diagnosis code and adjust the DRG is upheld.  
 
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 A41.9 rendered from June 30, 2022, to July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
September 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records only support a 
moderate level of decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (procedure code G0482) rendered on December 
20, 2022. 
 
You asked the Plan to pay for the services. You say that medical records were attached to support medical 
necessity. The Plan denied your request. The Plan says the documentation only supports testing for eight 
classes. 
 
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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed." 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, this code represents testing 
for 15-21 classes. The records only show that eight classes were tested. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for drug testing (procedure code G0482) rendered on December 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the prostate testing you received on September 12, 2022. 
 
You asked the Plan to hold you harmless for the prostate testing. You say that you have prostate cancer and this 
was not a screening test.  You said that you talked to your doctor and the doctor advised that the lab incorrectly 
billed this as a prostate screening test, when it was a diagnostic test. The Plan denied your request. The Plan 
says that you have exceeded the number of prostate screening tests that are covered in 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that you had already received a 
covered prostate screening test in 2022.  However, it does not appear that the Plan made any attempts at all to 
confirm the allegations you made in your appeal letter.  You specifically advised them that the lab that 
performed the testing at issue coded it incorrectly as a screening test.  This lab is a network provider.  The Plan 
has provided no evidence that it even attempted to get medical records to determine if the provider's coding 
was correct or not.  The Plan has made no efforts to confirm the billing of these services.  The burden is on the 
Plan to show why its denial was appropriate.  By failing to take any of these actions, we find that the Plan has 
not met this burden.  As a result, the Plan has an obligation to ensure that you are not held financially liable for 
this service. Therefore, we decided that the Plan has to hold you harmless for the prostate testing you received 
on September 12, 2022.  
 
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 pay for procedure code 99100 billed for date of service November 
28, 2022. 
  You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 8, 2023, to 
January 20, 2023. 
 
You asked the Plan to pay for the home health services. You say that you have billed the required Federal 
Information Processing Standard (FIPS) codes. The Plan denied your request. The Plan says you did not bill the 
FIPS code data correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that value code 85 is defined "County Where Service 
is Rendered." This code is required for home health claims to appropriately calculate county-based rural add-on 
payment amounts.  
 
In this case, you billed FIPS codes of 85 and 61.  We agree that these are valid codes.  However, you failed to 
bill any value amounts for either of these FIPS codes.  Amounts are required to appropriately calculate any 
add-on payments that may be applicable.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from January 8, 2023, to January 20, 2023.