Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services billed with diagnosis code N17.9 rendered 
from January 25, 2023, to January 30, 2023. 
 
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 that reasonable clinical evidence within the 
health record must be present to clinically validate the diagnosis. 
 
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 683. 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 supported by the medical records. Our physician reviewer found that 
the enrollee had an acute rise in creatinine from the baseline, secondary to urinary retention, thus meets the 
criteria for N17.9. Thus, the presentation more supports DRG 683, rather than DRG 389. 
 
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 billed with diagnosis code N17.9 rendered from January 25, 2023, to January 30, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo System 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollees clinical 
management.  
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo System
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP panel testing (81455) 
provided January 26, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the doctor regarded this test as a medically 
necessary and valuable tool when determining treatment for the enrollee. The Plan denied your request. The 
Plan says the requested test is not reasonable and necessary because Tempus xF is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. 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 patients cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP panel testing (81455) 
provided January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 28, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services . You say that this necessary care should be covered. The 
Plan denied your request. The Plan says this service is not covered when provided OON. 
 
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 the laboratory services provided on March 28, 
2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23020 rendered on January 12, 2023. 
 
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 23020 is "Capsular contracture release (eg, Sever type 
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 the procedure details cite the 
subscapularis tendon and capsular tissue was peeled off the lesser tuberosity. Tension was placed on the 
inferior capsule. The capsule was split inferiorly down to the 6 oclock position. The anterior and posterior 
capsule tissue as assessed and appeared to be contracted. Therefore, the anterior capsule was released from 1 
down to the 6 oclock position and then the posterior capsule from 9 down to the 6 oclock position. 
This was done in conjunction with dislocating the humeral head and overall exposure to perform the reverse 
total shoulder. Therefore, the records do not support this code. 
 
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 procedure code 23020 rendered on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the RST neoGen series rendered on August 8, 2022. 
 
You asked the Plan to pay for the services. You say that you would like the claim reprocessed and paid. The 
Plan denied your request. The Plan says there is no record for vitamin deficiencies, evaluation for a diagnosis 
requiring compression devices, or a prescription and receipt of physical therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no specific clinical rationale for this series. The medical literature does not support that this 
treatment is safe and effective, or represents a standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the RST neoGen series rendered on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Cxbladder Detect (0012M) provided December 29, 
2022. 
 
You asked the Plan to pay for  the laboratory service. You say that the evidence supporting the use of 
Cxbladder Detect as a medically necessary diagnostic service is well established and affirmed by Medicare. 
The Plan denied your request. The Plan says the medical literature does not support that the biomarkers 
included in Cxbladder Detect have proven clinical validity/utility in asymptomatic microscopic hematuria.  
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  the Cxbladder Detect (0012M) provided December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pulmonary rehabilitation services 
provided on February 07, 2023. 
 
You asked the Plan to waive the copayment for the pulmonary rehabilitation services. You say that you cannot 
afford the copayment. 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 $20 
copayment for pulmonary rehabilitation services. 
 
You have been asked to pay a $20 copayment for the pulmonary rehabilitation services. This item/service falls 
within the pulmonary rehabilitation services 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 copayment 
for the pulmonary rehabilitation services provided on February 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of implant; deep (eg, buried wire, pin, screw, metal 
band, nail, rod or plate) rendered on January 12, 2023. 
 
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 this was not reported correctly. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the use of CPT code 20680 is not 
supported. The record states that the hardware was removed as an integral part of a hip arthroplasty. According 
to National Correct Coding Initiative (NCCI) rules, in this situation CPT code 20680 cannot be reported separately. 
 
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 removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) rendered 
on January 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hip x-ray provided on October 10, 
2022. 
 
You asked the Plan to waive the copayment for the hip x-ray. You say that this was the result of previous 
procedures and should be 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 $35 
copayment for outpatient diagnostic tests, including x-rays.  
You have been asked to pay a $35 copayment for the hip x-ray. This item/service falls within the outpatient 
diagnostic tests, including x-rays 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. The record shows this claim was approved and you are responsible for the cost 
share amount. Therefore, we decided that the Plan does not have to waive the copayment for the hip x-ray 
provided on October 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit coded as 99283, J3490, 12001, 
90471, 90715, G0168, A4550, A4657, and A4245 provided November 5, 2022. 
 
You asked the Plan to pay for the emergency room visit. You say that you had cut two fingers and you take a 
blood thinner twice a day so you were bleeding profusely. This emergency room was 3 minutes away and other 
facilities are 30 minutes away. The Plan denied your request. The Plan says the services was rendered by a 
provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. This facility is not certified with Medicare and has not been granted temporary Medicare billing 
services. Therefore, the Plan cannot pay a provider who is not eligible to participate in Medicare. Therefore, we 
decided that the Plan does not have to pay for the emergency room visit coded as 99283, J3490, 12001, 90471, 
90715, G0168, A4550, A4657, and A4245 provided November 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on January 26, 2023. 
 
You asked the Plan to pay for the critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, diagnosis codes R06.02 
(Shortness of breath) and J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia) 
have an exclude note and should no be billed together. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (99291) provided on January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cologuard test provided on December 7, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that under federal law, you believe Cologuard is 
a covered service for this enrollee and should have been paid at the national Medicare rate established in the 
clinical lab fee schedule 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. 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 Cologuard test provided on December 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (86141) provided on September 20, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you were not able to obtain medical 
information timely. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until March 21, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (86141) provided on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87801, 87798) provided on 
October 22, 2021, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this service 
is not covered when provided OON. 
 
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 the laboratory services (87481, 87801, 87798) 
provided on October 22, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and surgical 
stockings (A4495) provided January 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and surgical stockings. You say that the medical 
records provided will show proof of medical necessity. The Plan denied your request. The Plan says the 
requested items are not covered benefits. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  Medicare rules say 
that elastic stockings are not covered because they are non-reusable supply items. Elastic stockings are not 
durable medical equipment. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD and surgical stockings have not been met. Specifically, these items are not covered 
benefits of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for 
treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676) and surgical stockings (A4495) 
provided January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on 
December 29, 2022. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. Once this is 
complete, the test is assigned a reimbursement rate and unique test identifier.  
We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on December 
29, 2022.