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 D69.6 
rendered from February 7, 2022, to February 11, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
appealing this partial recoupment with medical records. 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 code D69.6. 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 was admitted for routine transfusion and bone marrow biopsy was planned as 
outpatient. Hospice and comfort measures only were planned. The enrollee's thrombocytopenia is directly 
related to their myelodysplastic syndrome (MDS). Therefore, the primary diagnosis should be myelodysplastic 
syndrome and the code, D69.6, thrombocytopenia, would not be indicated for this admission as the MDS code 
includes the anemias associated with it. Therefore, the more appropriate DRG for this admission would be 
812.   
 
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 D69.6 rendered from February 7, 2022, to February 
11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86141, 87631, 87798) provided on January 9, 
2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The rules also state that Respiratory Pathogen Panels 
that test for more than 5 pathogens are considered not medically necessary and are non-covered. 
 
Code 86141 was requested solely for screening purposes. Medicare does not cover this test solely for screening 
purposes. Codes 87631 and 87798 are part of a panel with more than 5 pathogens and are non-covered. 
Therefore, we decided that the Plan does not have to pay for lab services (86141, 87631, 87798) provided on 
January 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay additional payment for the outpatient surgery provided 
November 8, 2022. 
 
You asked the Plan to pay additional payment for the outpatient surgery. You say that you were told by the 
Plan that you would be fully reimbursed. However, when the appeal was processed you was only reimbursed 
$554.83. The Plan denied your request. The Plan says the claim processed correctly per the 2022 benefit. The 
Plan made payment according to the Medicare allowable rate. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient surgery have not been met. Specifically, the record indicates that the Plan has paid 
the Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed 
amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay additional payment for 
the outpatient surgery provided November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on January 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are not covered by Medicare when the place of service is an ambulatory 
surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
The records show that the requested items were billed with place of service 24, which is an ambulatory surgical 
center. Medicare rules state that for durable medical equipment to be covered, it must be appropriate and be 
needed for use inside the home. Medicare does not consider an ambulatory surgical center a home. Therefore, 
we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81226, 81291) provided 
on February 7, 2023.  
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says this test was provided as a routine test for medication 
selection. 
 
The Plan follows Medicare rules. Medicare rules say that once the putative therapeutic agents are selected, and 
those agents are known to have gene-drug interactions as identified above, then a PGx test may be considered 
reasonable and necessary when the result of that test is necessary for the physicians decision-making process 
regarding safely administering or dosing the drug. 
 
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 GeneSight Psychotropic testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that based on review 
the records provided there is documentation of this enrollee having tried at least one medication (amitriptyline) 
which is noted although there is no documentation of the enrollee responding to the medication. The rules 
require that the enrollee be tried on at least one medication. The ordering psychiatrist must be board certified in 
psychiatry or neuropsychiatry. The documentation shows that the enrollees testing was not used for selection 
of medication as noted. This enrollee was not undergoing severe depressive symptomatology. The enrollee 
does not meet the criteria for GeneSight Psychotropic Assay and is considered medically necessary and 
reasonable in the treatment of this individual. 
 
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 GeneSight Psychotropic testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the GeneSight Psychotropic testing (81226, 81291) provided on February 
7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 4, 2022, to 
March 5, 2022. 
 You asked the Plan to pay for the home health services. You say that the Plan has not told you the exact denial 
reason for this claim. The Plan denied your request. The Plan says the valid NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2022. The NOA was not received by the Plan until June 1, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
February 4, 2022, to March 5, 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 October 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. 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 October 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99358 billed for date of service February 1, 2023. 
 
You asked the Plan to pay for code 99358. You say that this code should be separately paid. The Plan denied 
your request. The Plan says code 99358 is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that code G2212 is to be used for billing prolonged 
services instead of code 99358. You billed code 99358, which is no longer to be used to bill for prolonged 
services for Medicare patients. Therefore, we decided that the Plan does not have to pay for code 99358 billed 
for date of service February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive PGX panel provided on March 21, 2022, 
and billed with codes 81407, 81238, 81226, 0033U, 81225, 81306, 81406, 81227, 81230, and 81232. 
 
You asked the Plan to pay for the comprehensive PGX 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 comprehensive PGX panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the comprehensive PGX panel provided on March 21, 2022, and billed with codes 81407, 81238, 81226, 0033U, 81225, 81306, 81406, 81227, 81230, 
and 81232.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Botox (J0585). 
 You asked the Plan to pre-approve the Botox. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our reviewer says that the 
enrollee has not met the step therapy requirements. Our physician reviewer found the patient has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 Botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery services provided on February 
17, 2021, to February 25, 2021. 
 
You asked the Plan to waive the copayment for the surgery services. You say that you should not have been 
billed for this surgery. 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 $175 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $175 copayment for the surgery services. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 surgery services provided on February 17, 2021, to February 25, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diagnostic contrast dye provided on 
March 01, 2023. 
 
You asked the Plan to waive the coinsurance for the diagnostic contrast dye. You say that you were not told 
about the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the diagnostic contrast dye. This item/service falls within the 
Medicare Part B prescription drugs 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 total you owe is $51.37 ($256.83 allowed amount x 20% = $51.37). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the diagnostic contrast dye 
provided on March 01, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee can benefit from more services. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for SNF continuation.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a sleep study with an out-of-network provider. You say that you are 
requesting reconsideration for the denied authorization stating a new provider is noted within the  
appeal. The Plan denied your request. The Plan says this provider is out-of-network. The services are available 
in-network. 
   
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a sleep study to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel provided on 
February 10, 2023. 
 
You asked the Plan to pay for targeted genomic sequence analysis panel. 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 targeted genomic 
sequence analysis panel provided on February 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 23, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services. You say that the in-plan providers have not been able 
to give you a diagnosis. You say this provider is a world-renowned parathyroid expert and you would like a 
consultation and possible treatment relating to hyperparathyroidism. The Plan denied your request. The Plan 
says there are participating/network providers available to render the requested care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy exercises, and electrical stimulation 
provided on October 04, 2022. 
 
You asked the Plan to pay for occupational therapy exercises, and electrical stimulation. You say that these 
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 occupational therapy 
exercises, and electrical stimulation provided on October 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 13, 2022. 
 
You asked the Plan to pay for these chiropractic services. You say that you had a rib out of place and the 
chiropractor has provided relief. The Plan denied your request. The Plan says the denial of payment for these 
services was correct. 
 
  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided on December 13, 2022.