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

 
We decided that the Plan has to pay for the Tempus xF genetic panel (81455) provided August 1, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says that the 
requested test is not reasonable and necessary because Tempus xF has not had FDA approval or clearance as a 
companion in vitro diagnostic or an FDA-approved or cleared indication for use in this patient's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it 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 pay for the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee with a diagnosis of cancer based on the following 
symptoms and clinical findings: malignant carcinoid tumors of other sites: C7A. The review has determined 
that the items/services at issue in this case are 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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for the Tempus xF genetic panel (81455) provided August 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service December 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided supporting documentation to 
pay 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 the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed for date of service 
December 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 5, 2022, to 
April 11, 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 
medical records support the billing of secondary diagnosis code N17.0 (Acute kidney failure with tubular 
necrosis). The Plan denied your request. The Plan says the medical records do not support the billing of 
secondary diagnosis code N17.0 (Acute kidney failure with tubular necrosis). 
 
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 N17.0. 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 medical records do not support the billing of secondary diagnosis code N17.0 (Acute kidney failure 
with tubular necrosis). Our physician reviewer found there was no clinical or laboratory evidence of acute 
kidney failure with tubular necrosis. The serum creatinine levels while acutely elevated in the setting of urinary 
retention responded to IV fluids and Foley catheter insertion and was noted as 2.2 mg/dL, BUN 25.8 mg/dL 
BUN/creatinine ratio 11.7 and eGFR 28.9 mL/minute on April 9, 2022, and was 1.0 mg/dL, BUN 12.2 mg/dL, 
BUN/creatinine ratio 12.2 and eGFR greater than 60 mL/minute on the day of discharge. The review has 
determined that the documentation did not support N17.0.  
 
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 April 5, 2022, to April 11, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care from March 8, 2021, through July 22, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says that the itemized bill charges are greater than the claim charges. 
 
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. The Plan did not include an itemized bill to verify if the amount is different than 
the claim amount, therefore, we cannot confirm that the amounts are different. Therefore, we decided that the 
Plan has to pay for inpatient hospital care from March 8, 2021, through July 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periapical radiographic imaging (D0220/D0230), a 
periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based composites (D23331/D2335) provided 
on November 8, 2022, to November 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for periapical radiographic imaging 
(D0220/D0230), a periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based composites 
(D23331/D2335) provided on November 8, 2022, to November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for code J3490. You say that this claim was billed correctly. The Plan denied your 
request. The Plan says you billed this item with the wrong code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, code J3490 is used to bill for unclassified drugs.  According to the medical records, the provider 
dispensed Faricimab-svoa.  Faricimab-svoa is a biologic.  As a result, it should have been billed using the 
unclassified biologic code, which is J3590. Therefore, we decided that the Plan does not have to pay for code 
J3490 billed for date of service July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided on 
December 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that the F1CDx test is not available through any 
other laboratory and thus would not be available through in-network laboratories. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being 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. The records also do not show that the enrollee has either recurrent, relapsed, refractory, 
metastatic, or advanced stage III or IV cancer, or that the enrollee has decided to seek further cancer treatment. 
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 the FoundationOne CDx (F1CDx) test (0037U) provided on December 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 16, 2022, to 
August 18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the provided inpatient services were 
medically necessary. The Plan denied your request. The Plan says that the enrollee did not meet criteria for 
inpatient admission. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the enrollee presented to the emergency department (ED) on August 
16, 2022, after a fall. He tripped over a garden hose. The evaluation revealed non-displaced fractures of the 
right radial head and left patella. There was no loss of consciousness and no head trauma. The fractures did not 
require surgery for management, but the decision was made to admit him simply because he could not easily 
use a walker or crutches to ambulate with an expectation that he might need rehabilitation. On August 17, 
2022, the pain was described as well-controlled, and Orthopedics indicated that the status of the left leg was 
weight bearing as tolerated. They also documented quite clearly, He does not require continued inpatient 
care for his orthopedic issue. The enrollee was hemodynamically and neurologically stable. 
throughout his stay, and his fracture did not involve the femur, hip, or pelvis. He was discharged home on 
August 18, 2022. 
 
The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 16, 2022, to August 18, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (61781) provided on December 6, 
2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 61781. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 surgical assistant services. Our reviewer 
says that these services are not supported in the record. Our physician reviewer found the provided records in 
this case do not document medical necessity of the assistant for the procedure performed. 
 
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 surgical assistant services have not been met. Therefore, we decided that the 
Plan does not have to pay for surgical assistant services (61781) provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service September 22, 2022. 
 
You asked the Plan to pay for code 99233. You did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says the medical records do not support the billing of code 99233 for 
date of service September 22, 2022 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. 
 
 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 code 99233. Our reviewer says that code 99233 is not 
supported in the medical record. Our reviewer found the patient is a 76-year-old male who was treated in the 
hospital with respiratory failure. Code 99223 was submitted for treatment provided on Sept 22, 2022. On that 
date the note provided described the patient as requiring high flow oxygen without other symptoms and was 
brief and focused. Documented physical findings were basic and not detailed. The patient was stable otherwise. 
No significant changes in the treatment were made. There was insufficient support made in the provided 
documentation that this note described a detailed history or physical, nor was there evidence of medical 
decision-making of high complexity.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test is medically necessary and is a covered 
benefit. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that you feel that this scooter is necessary for 
you. The Plan denied your request. The Plan says there is no documentation that the member has been 
evaluated by a qualified rehabilitation professional. Additionally, the member was approved for a standard 
manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power scooter. Our reviewer says 
that the records do not support the medical necessity of the requested power scooter. Our physician reviewer 
found the documentation does not indicate the member has been evaluated by a skilled rehabilitation 
professional to determine his mobility needs and if he is safe to operate a PMD. There is also no clear 
documentation to indicate his mobility needs cannot be met with a manual wheelchair. The requested PMD 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 the power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99183 billed for date of service August 24, 
2022.  
You asked the Plan to pay for procedure code 99183. You say that this claim should be paid. 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 99183 is 1. The MAI value for this code is 3. You billed 3 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 99183 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99183 billed for date of service August 24, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on August 19, 2022, through 
August 21, 2022, and billed with diagnosis code R65.21. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis R65.21 is supported by the records. The Plan denied your request. The Plan says that the 
documentation submitted does not support secondary diagnosis of R65.21. 
 
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 R65.21-Severe sepsis 
with septic shock. 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 documentation does support the secondary 
diagnosis of R65.21-Severe sepsis with septic shock. Our physician reviewer found the member presented with 
chills, sweats, and gastrointestinal symptoms. The member was found to be hypotensive, bradycardic, and 
hypothermic. The diagnostic testing revealed leukocytosis, acute kidney injury (AKI), acidosis and enteritis. 
The diagnoses of sepsis and septic shock is warranted. 
 
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 August 19, 2022, through August 21, 2022, and billed with diagnosis code 
R65.21.  
 
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.