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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 13, 2023, to 
January 15, 2023, 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 
enrollee's severe sepsis was likely due to diverticulitis and was clinically present. Therefore, this claim was 
properly coded. The Plan denied your request. The Plan says the primary diagnosis code A41.9 (Sepsis 
unspecified organism) and secondary diagnosis code R65.20 (Severe sepsis without septic shock) are not 
supported by the medical record. As a result, diagnosis K57.92 (Diverticulitis of intestine, part unspecified, 
without perforation or abscess without bleeding) is the correct primary diagnosis, so a lower DRG was paid. 
 
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 primary diagnosis code A41.9 (Sepsis unspecified 
organism) and secondary diagnosis code R65.20 (Severe sepsis without 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 billed primary diagnosis code A41.9 (Sepsis unspecified organism) and secondary 
diagnosis code R65.20 (Severe sepsis without septic shock) are not supported by the medical record. Our 
physician reviewer found the enrollee is a 66-year-old man with history of heart failure and kidney transplant 
recipient, who was admitted with diverticulitis. The enrollee had creatinine of 1.28 (baseline 1.1). He was 
afebrile and had a normal heart rate and white blood cell count. He was treated with Augmentin. The enrollee 
had diverticulitis but does not meet criteria for severe sepsis either by Systemic Inflammatory Response 
Syndrome (SIRS) criteria or end-organ damage, so A41.9 and R65.20 are 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 January 13, 2023, to January 15, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 99222. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 1, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for procedure code 99222 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222 billed for date of service 
November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Hereditary Cancer Panel for Cancer Screening 
provided on April 5, 2023. 
 
You asked the Plan to pay for the CGx Hereditary Cancer Panel. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the CGx Hereditary Cancer Panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the CGx Hereditary Cancer Panel for 
Cancer Screening provided on April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee was not responsive to 
BiPAP therapy and requires non-invasive ventilation (NIV) to stabilize their ventilation.  The Plan denied your 
request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be 
met with an alternative device such as a BiPAP device with average volume-assured pressure support 
(AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that although the 
enrollee has COPD and chronic respiratory failure, the documentation does not show or support failure of 
BiPAP or BiPAP with AVAPS therapy. Therefore, the request does not meet the requirements of a home 
ventilation system. 
 
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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-network telehealth services provided on June 2, 
2023 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees must pay a $0 copayment for virtual visit services provided by an in-network provider.  
 
Review of the file shows that out-of-network telehealth services were provided on June 2, 2023. The Plan 
contract clearly states that telehealth services are only covered when provided by an in-network provider. 
Therefore, we decided that the Plan does not have to pay for the out-of-network telehealth services provided on 
June 2, 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 you will not get the rehabilitation needed at a lower 
level of care to recover and go home . The Plan denied your request. The Plan says an IRF admission is not 
medically necessary.  
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
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 SNF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the SNF admission.  
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not qualify for SNF coverage. You do not have skilled nursing or skilled 
therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your current condition. Your care needs, custodial and intermittent, can, as a practical matter, 
be provided at a lower level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the data in the published literature fails to show efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has upper extremity weakness following a 
stroke. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthotic device.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the cost share for an emergency room (ER) visit provided on April 16, 
2023. 
 
You asked the Plan to waive the cost share for an ER visit. You say that you disagree with the cost share 
applied. The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
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 failed to provide the necessary documentation to justify the cost share 
applied for an ER visit. Therefore, we decided that the Plan has to waive the cost share for an emergency room 
(ER) visit provided on April 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 30, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acne surgery provided on April 20, 2023. 
 
You asked the Plan to pay for the acne surgery. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service was cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the acne surgery have been met. No 
medical records were provided for our review. Therefore, we decided that the Plan does not have to pay for 
acne surgery provided on April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 18, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 18, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 
87500.
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 you require assistance because you are unable to do 
things by yourself. You say that you need physical therapy because you are not able to walk . The Plan denied 
your request. The Plan says an IRF admission is not medically necessary.  
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
testing (87798, 87635, 87541) provided on May 21, 2023. 
 
You asked the Plan to pay for the respiratory PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory panel for more than 5 pathogens are 
not covered. 
 
We looked at the file and Medicare rules. In this case the panel at issue tested for more than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of the respiratory PCR 
panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
polymerase chain reaction (PCR) panel testing (87798, 87635, 87541) provided on May 21, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on April 24, 2023. 
 
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on April 23, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components, a detailed interval history; a 
detailed examination; medical decision making of high complexity (99223) provided on March 11, 2022, to 
March 12, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says code 99223 remains not 
supported. This code requires two out of three key components. 
 
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 subsequent hospital care. Our reviewer says that the service 
does not meet criteria for payment on this claim. Our reviewer found per CPT code description " which 
requires at least 2 of these 3 key components, a detailed interval history; a detailed examination; medical 
decision making of high complexity". In this case, documentation for this date of service does not include 
documentation to support a detailed interval history. An interval history is what happened to the enrollee 
between the time the medical doctor (MD) visits. Documentation does not support a high complexity medical 
decision making to include complexity of a physician's work that is necessary to establish a diagnosis and/or to 
select a healthcare management option. There is a more appropriate CPT code to report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for subsequent hospital care, per day, for the evaluation and management of a patient, 
which requires at least 2 of these 3 key components, a detailed interval history; a detailed examination; medical 
decision making of high complexity (99223) provided on March 11, 2022, to March 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula (B4155). 
 
You asked the Plan to pre-approve enteral formula. You say that the requested item is a necessity for your care. 
The Plan denied your request. The Plan says rules for coverage for enteral formula have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered for an enrollee who 
requires feedings via an enteral access device. Adequate nutrition must not be possible by dietary adjustment 
and/or oral supplements. 
 
 
  We looked at the file and Medicare rules. In this case, the provided medical records do not support that you are 
unable to absorb oral nutrition. Based on this information, we decided that Medicare rules for coverage of 
enteral formula have not been met. Therefore, we decided that the Plan does not have to pre-approve enteral 
formula (B4155).