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

 
We decided that the Plan does not have to pay for ambulance transportation services (A0427, A0425) provided 
on September 10, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services are supported in the medical 
record and should be paid. The Plan denied your request. The Plan says the payment for this service is included 
in the facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the record shows that the enrollee was 
inpatient status at one facility from September 9, 2022, to September 14, 2022. This means that the services at 
issue are considered patient transportation and paid to the facility. Therefore, we decided that the Plan does not 
have to pay for ambulance transportation services (A0427, A0425) provided on September 10, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 49560 billed for date of service November 16, 2022. 
 
You asked the Plan to pay for procedure code 49560. You say that this service was reported correctly. The Plan 
denied your request. The Plan says that this procedure is included in code 49650 which was also billed for this 
date of service. This code does not qualify for separate reporting in this case. 
 
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 49560 is repair initial incisional or ventral hernia; reducible. 
 
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 procedure code 49560. Our reviewer says that this code is 
supported in the medical record. Our reviewer found the procedure report describes two distinct hernia repairs, 
and therefore should be covered.  Of note, there is no National Correct Coding Initiatives (NCCI) edit between 
codes 49650 and 49560. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 49560 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 49560 billed for date of service November 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code N17.9 
rendered from September 17, 2020, to September 21, 2020. 
 
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 DRG was updated. 
 
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 N17.9. 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 enrollee presented with presyncope. The enrollee was found to have bradycardia and 
treated for subjective dehydration. The enrollee had a history of chronic kidney disease.  While his baseline 
creatinine was unknown, his renal studied remained stable throughout the hospitalization. As such, there is no 
evidence of acute or acute-on-chronic renal failure. The billing of N17.9 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 billed with diagnosis code N17.9 rendered from September 17, 2020, to 
September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0452 billed for date of service September 9, 2022. 
 
You asked the Plan to pay for code G0452. You say that this service is supported in the medical record. The 
Plan denied your request. The Plan says the payment for this service is included in the payment for other 
services provided on the date in question. 
 
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, we have confirmed that code G0452 is a column II code to column I code 81301 and 81455; 
however, G0452 was billed with a modifier.  
 
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 G0452. Our reviewer says that this service is not 
supported for separate payment. Our reviewer found the medical records provided do not include sufficient 
information to validate that G0452 was performed as a distinct/separate service from CPT codes 81455 and 
81301. Therefore, the use of the 59 modifier and reporting G0452 are not supported. 
 
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 G0452 have not been met. Therefore, we decided that the Plan does not 
have to pay for code G0452 billed for date of service September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography services provided on December 2, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON echocardiography services. You say that you had been to this OON 
provider 7 years ago due to a curved Aorta and they told you to return in 5 years. You say that you also went 
for a cough that no doctor in Buffalo had found the cause of. You say that the OON discovered what was 
causing the cough and referred you to a rheumatologist. You say that, had you not gone to see the OON 
provider, this need would not have been found.  The Plan denied your request. The Plan says medically 
necessary care was available within the network. Prior authorization was not obtained for the OON services.  
 
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 echocardiography services provided on December 
2, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740 x1) and prefabricated post and core in 
addition to crown (D2954 x1). 
 
You asked the Plan to pre-approve the dental services. You say that you have been bleeding and need this 
service to be covered. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on May 31, 2023 when the Plan authorized 
crowns x3 and prefabricated post and core in addition to crown x3. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2740 x1) and prefabricated post and core in addition to crown (D2954 x1).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of i-Factor allograft for spinal surgery (20930). 
 
You asked the Plan to pre-approve i-Factor allograft. You say that i-Factor allograft is 
experimental/investigational. The Plan denied your request. The Plan says i-Factor allograft is a medical 
necessity for the enrollee. 
 
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 i-Factor allograft. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found i-Factor allograft is experimental. More research is needed to demonstrate its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of i-Factor allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the use of i-Factor allograft for spinal surgery (20930).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing provided on October 11, 20222. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was billed 
with a missing/invalid test identifier. 
 
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 argues that the claim was billed with a missing/invalid test identifier. 
However, the submitted claim was billed with test identifier "ZB1CW". The Plan has not provided 
documentation showing that this code is incorrect for the billed testing. Without supporting documentation, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the testing provided on 
October 11, 20222.  
 
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: Favorable

 
We decided that the Plan has to pay for an inpatient readmission provided on May 23, 2022, to June 8, 2022. 
 
You asked the Plan to pay for an inpatient readmission. You say that this readmission was medically necessary. 
The Plan denied your request. The Plan says that this admission was correctly denied. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 an inpatient readmission. Our reviewer says 
that the medical criteria for a readmission was met. The review indicates that the readmission was medically 
necessary was not the result from a premature discharge from the same hospital.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient readmission have been met. Therefore, we decided that the Plan has 
to pay for an inpatient readmission provided on May 23, 2022, to June 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377) electrical harness 
(E2313) and electronic connection (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please review the attached supporting 
documents for the prior authorization request. The Plan denied your request. The Plan says the upgraded 
electronics are 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 pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has left hemiparesis but per record is able to perform self-catheterization 
intermittently. Per SSA 1862 (a)1(A) as the enrollee has adequate strength to manage standard power drives the 
upgraded electronics are not medically necessary to meet the enrollee's needs. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the expandable controller (E2377) electrical harness (E2313) and electronic 
connection (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a right total knee arthroplasty. You say that the requested knee replacement 
is medically necessary. The Plan denied your request. The Plan says that this procedure 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 pre-approve a right total knee arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the detailed documentation is not evident regarding end-stage 
osteoarthritis of the right knee. Additionally, a trial and failure of all reasonable, comprehensive, less invasive 
conservative care measures are not evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception.  
 
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 right total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right total knee arthroplasty (27447).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code J15.6 
rendered from August 23, 2022, to August 25, 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 DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 177. 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 there is no evidence that a gram-negative organism was detected.  As such, the billing of J15.6 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 billed with diagnosis code J15.6 rendered from August 23, 2022, to August 25, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The 
Plan denied your request. The Plan says the requested Hyalgan is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Hyalgan. Our reviewer says that the 
requested Hyalgan is not medically necessary. Our physician reviewer found according to the reviewed 
literature, viscosupplementation after knee replacement has not been proven to be beneficial. The review has 
determined that the requested use of Hyalgan is not FDA-approved for the enrollees diagnosis. Its 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on January 11, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for testing services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 testing services provided on January 11, 2023, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 9, 2022, to 
August 16, 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 principal diagnosis code A41.9. The Plan denied your request. The Plan 
says the medical records do not support the billing of principal diagnosis code A41.9. 
 
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 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 medical records do not support the billing of principal diagnosis code A41.9. Our physician reviewer 
found the enrollee is with chronic kidney disease (CKD) who presented to the emergency department with 
altered mental status for one week with decreased food and water intake due to difficulty swallowing, nausea, 
and vomiting. She was noted to be disoriented. Cr was 1.8, BUN 33. Urinalysis and urine culture showed 
urinary tract infection which was treated with antibiotics and supportive care including fluids. Following initial 
treatment. Repeat Cr was between 1.7 and 1.9. Vitals were stable on admission without hypoxia. Platelets were 
normal, bilirubin was normal, MAP was not less than 70, and there was no notable oliguria. Based on the 
objective workup for this enrollee on this admission, there was only encephalopathy noted which would be 
insufficient alone to meet Sepsis 3 criteria. There was insufficient evidence to show the enrollee's infection led 
to a life-threatening dysregulated response causing organ failure. Therefore, the code, A41.9 (sepsis) 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 August 9, 2022, to August 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.