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

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code G92.8 
rendered from January 19, 2022, to January 28, 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 assignment for this case is 
appropriately changed from DRG 637 to DRG 638. 
 
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 G92.8. 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 based on the medical records provided there is no documentation that fully supports 
diagnosis code G92.8 - other toxic encephalopathy. The records in this case consistently document the 
diagnosis of anion gap metabolic acidosis with diabetic ketoacidosis but do not consistently document toxic 
encephalopathy to meet Medicare criteria for the DRG code 637.  
 
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 G92.8 rendered from January 19, 2022, to January 28, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve methotrexate.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service November 
10, 2022.  
 
You asked the Plan to pay for procedure code 99232. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99232 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service November 10, 2022.
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 medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 the enrollee does not require treatment by multiple therapies. 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 lab services provided on August 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim was billed appropriately and these 
services were ordered by a referring physician. 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 August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 related to end-stage renal disease (ESRD) provided on 
December 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with codes B, C, G 
rendered from May 18, 2022, to July 1, 2022. 
 
You asked the Plan to pay for the services. You say that you are attaching medical records for review. The Plan 
denied your request. The Plan says there is missing documentation.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 terms of the denied charges for 
denial code ($2,602.86), the provider reported ambulatory recovery 1st hour for dates of service June 14, 2022 
and June 15, 2022, and ambulatory surgery recovery, 1st hour for June 15, 2022, as well as Alteplast injection, 
per 1mg. These services were not found in the medical records, and therefore cannot be verified. The denied 
charges for code G were found to be routine and unbundled services, and not reimbursable 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 inpatient hospital services denied with codes B, C, G rendered from May 18, 2022, to July 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on January 15, 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. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
medical records provided does not include sufficient documentation to validate that procedure 99152 was 
performed as a distinct or independent service from procedure (CPT) 45385 that was performed during the same operative session on January 25, 2023 
 
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 moderate sedation services (procedure code 99152) rendered on January 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on December 6, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this is a covered service. The Plan denied 
your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Molecular Diagnostic Services Program 
(MolDX) will review all new test/assay clinical information to determine if a test meets Medicares reasonable 
and necessary requirement. 
 
We looked at the file and Medicare rules. MolDX has determined that DecisionDx-SCC testing does not meet 
Medicares reasonable and necessary requirement. Based on this information, we decided that Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the Plan does not have 
to pay for DecisionDx-SCC testing (0315U) provided on December 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti. 
 
You asked the Plan to pre-approve Kanjinti. You say that this is medically necessary. The Plan denied your 
request. The Plan says this use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Kanjinti. Our reviewer says that the 
requested use of Kanjinti is not supported. Our physician reviewer found Kanjinti is FDA-approved for 
treatment of patients with human epidermal growth factor receptor 2 (HER2)-positive (HER2 overexpression) 
breast cancer. The enrollee in this case has a diagnosis of stage IV breast cancer (which is negative for HER2 overexpression). The use in this situation is also 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 Kanjinti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kanjinti.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2011 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code H2011. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2011 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2011 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code H2011 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2011 billed for date of service July 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (procedure code 99222) rendered on August 22, 
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 that Current Procedural Terminology (CPT) code 99222-57 (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 supported by the medical records. Our reviewer found that the health plan has argued that the 
documented examination is not comprehensive.  The examination is comprehensive, but it is specialty specific. 
Basic examination of the enrollees vital signs, general appearance, heart, lungs, skin and psychiatric state are 
noted. Comprehensive examinations of all extremities and the pelvis are documented.  It is specifically noted 
that gait was not assessed due to the nature of the enrollees injury.  In total, this examination is comprehensive 
given the consultants specialty.  As such, the billing of CPT 99222 is 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 the services have been met. Therefore, we decided that the Plan has to pay for 
initial hospital care (procedure code 99222) rendered on August 22, 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 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 medically necessary for the enrollee 
to receive the care needed.  The Plan denied your request. The Plan says the therapy required for the enrollee is 
not therapy that is uniquely provided in an IRF.  
 
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 the enrollee does not require treatment by multiple therapies. 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: 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 enrollee will benefit acute rehabilitation to 
optimize the level of functioning prior to returning home. The Plan denied your request. The Plan says the 
enrollee does not meet medical necessity criteria for admission to inpatient rehabilitation. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 enrollee requires 24 hour nursing and direct 
physician oversight. The Plan denied your request. The Plan says the enrollee's records do not show that you 
have complex rehabilitation needs that require frequent evaluation by a rehabilitation doctor. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient stay post-surgery for a total knee 
arthroplasty (27447). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that an inpatient stay for total knee arthroplasty (27447) is not on the 
Centers for Medicare & Medicaid Services (CMS) inpatient only list. This service (total knee arthroplasty) 
does not require authorization. The enrollee is medically stable and there is no documentation provided 
indicating medical necessity for inpatient level of care services for the approved procedure. The review has 
determined that the record did not show that the admitting physician reasonably expects that the enrollee's 
necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the inpatient stay post-surgery for a total knee arthroplasty (27447).