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

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that you suffer from debilitating and 
extreme nausea all day every day. You say that you had bloodwork, ultrasound of abdomen, and tried different 
nausea and stomach medications to no avail. You also say that your doctor recommended the camera 
endoscopy as opposed to the potential risks you would be exposed to by a regular endoscopy and colonoscopy 
at your age with all of your medications. The Plan denied your request. The Plan says the requested service is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is 
payable only once per episode of illness for patients who have previously undergone an upper gastrointestinal 
(GI) endoscopy, and lower GI colonoscopy, but have failed to reveal a source of bleeding. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the requested wireless capsule endoscopy is not medically necessary. Our physician reviewer 
found the requested procedure is indicated when upper endoscopy and colonoscopy do not reveal a source of gastrointestinal bleeding. The documentation does not support that the enrollee has had either. Therefore, the 
reviewer found that the requested wireless capsule endoscopy procedure is not medically reasonable or 
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 a wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of neck and chest. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that the enrollee had been 
treated for thyroid cancer in 2018, and then resected for recurrence in 2020, followed by radiation therapy in 
2021. The request for a six-month surveillance CT of the neck/chest after the last scans in 12/14/22 is 
reasonable, especially given the presence of the pulmonary nodules. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of neck and chest.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 5, 
2023. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee fell and needs continuous rehabilitation. 
You say it isn't safe for the enrollee to live independently again. The Plan denied your request. The Plan says 
that your request for approval of continued admission in a skilled nursing facility does not meet the 
requirements for approval. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before July 5, 2023. Specifically, the NOMNC submitted in the case file is not signed to support the 
enrollee or representative was properly notified. The Plan must pay for SNF services until the 100-day SNF 
care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we 
decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 5, 2023.  
 
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 a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
September 16, 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 Current Procedural Terminology (CPT) code 99222 (1 unit) remains not supported. 
 
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 99222 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 moderate 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 moderate severity. Typically, 50 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 although there is a comprehensive 
exam, the documentation does not reflect a comprehensive history or medical decision making of moderate 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99222) rendered on September 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing. 
 
You asked the Plan to pre-approve BRCA testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says there is no documentation that the enrollee has a personal history of a 
qualifying cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing of individuals 
with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is 
not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to pre-approve 
BRCA1 and BRCA2 genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four additional units of procedure code 95999 rendered on 
June 14, 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 coding and billing requirements were not met. 
 
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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." 
 
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 in this case, train of four would 
be included in the primary neuromonitoring procedure. There is no procedure code assigned for train of four. 
The code and units billed cannot be verified, as this procedure and the units were incorrectly reported. 
 
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 four additional units of procedure code 95999 rendered on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services billed with diagnosis codes 
A41.9 and R65.21 rendered from March 22, 2022, to March 29, 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 codes A41.9 and R65.21. 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 to the hospital with shortness of breath and was started on 
bilevel positive airway pressure (BiPAP), fluids, steroids, antibiotics for pneumonia and chronic obstructive 
pulmonary disease (COPD) exacerbation. Creatinine, platelets, bilirubin. and blood pressure were each 
normal/stable following initial fluids. There was no report of oliguria, and the enrollee was alert and oriented. 
Based on these findings, the documentation does not sufficiently support the billed diagnosis codes. The 
enrollee does not meet the Sepsis 3 criteria. There was insufficient evidence supporting the patient 
experiencing a dysregulated response to infection leading to life-threatening organ damage. Therefore, the 
records more support DRG 193.  
 
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 acute inpatient hospital services billed with diagnosis codes A41.9 and R65.21 rendered from March 22, 
2022, to March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 03, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on January 03, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from February 8, 2023, to 
February 9, 2023. 
 You asked the Plan to pay for the inpatient admission. You say that the services rendered were related to an 
emergency admission. You also say that the provided medical records justify medical necessity of this service. 
The Plan denied your request. The Plan says there is no provider attestation that the anticipated length of stay 
was expected to exceed 2 midnights. 
 
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 the inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the hospital for a cardiac catheterization procedure and was 
found to have an 80% obstructing lesion that was stented without complication. There was no bleeding, no 
cardiac abnormality or hemodynamic instability. Our reviewer also found that it was not expected that the 
enrollee would require hospital services that would likely cross 2 midnights based on the provided 
documentation.  
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from February 8, 2023, to February 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service October 7, 
2022, to October 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the bill type is correct. The Plan denied your 
request. The Plan says an NOA was not submitted. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that a notice of admission was not submitted as required. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home health care billed for dates of service October 7, 2022, to October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80048, 85027, and P9603 billed for date of 
service July 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was denied incorrectly. The Plan 
denied your request. The Plan says the services are included in the inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the lab CPT codes 80048, 85027, and P9603 are included in the payment to the facility. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 80048, 85027, and P9603 billed 
for date of service July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit provided on November 30, 
2022, and the eye exam and the ultrasound provided on December 12, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visit, the eye exam and the ultrasound. 
You say that you thought you were fully covered. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for diagnostic lab services and diagnostic procedures and tests. Your contract with the Plan also 
clearly says that you must pay a $20 copayment for each basic imaging service. Your contract with the Plan 
also clearly says that you must pay a $35 copayment for each in-person specialist visit. 
 
You have been asked to pay a $35 copayment for the specialist office visit provided on November 30, 2022. 
This item/service falls within the physician/practitioner services, including doctor's office visits benefit 
category. You have also been asked to pay a $5 copayment for the eye exam provided on December 2, 2022. 
You have also been asked to pay a $12.37, which is less than the standard copayment for the ultrasound 
provided on December 2, 2022. These items/services fall within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category.  This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office 
visit provided on November 30, 2022, and the eye exam and the ultrasound provided on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82728, 83540, and 83550) related to 
end-stage renal disease (ESRD) provided on February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (82728, 83540, and 83550) related to end-stage renal disease 
(ESRD) provided on February 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 to pre-approve. Our reviewer says that 
the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found as you are functioning at a home care level for rehabilitation, the services are 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 to pre-approval have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.