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 May 22, 2022, to 
May 27, 2022, 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 
medical records clearly demonstrate the diagnoses as billed.  The Plan denied your request. The Plan says the 
billed primary diagnosis of A41.59 (Other Gram-negative sepsis) and secondary diagnosis E87,1 (hypo 
osmolality and hyponatremia) are not supported by the medical record. As a result, 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 a primary diagnosis of A41.59 (Other Gram-
negative sepsis) and secondary diagnosis of E87,1 (hypo osmolality and hyponatremia). 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 of A41.59 (Other Gram-negative sepsis) and secondary 
diagnosis E87,1 (hypo osmolality and hyponatremia) are not supported by the medical record. Our physician 
reviewer found the enrollee presented with a recurrent abdominal wall infection.  She was confirmed to have an 
abdominal wall abscess/cellulitis, but was clinically ruled out for necrotizing fasciitis.  There is no evidence of 
hypotension, hypoperfusion, organ failure or hyponatremia.  As such, the diagnoses of sepsis and hyponatremia 
re 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 May 22, 2022, to May 27, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 25, 2023. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the claim 
was billed with the wrong date of service. 
 
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 payment for codes G0482 and 80307 is not supported in the medical record. Specifically, the 
records show that the drug testing services were provided on January 26, 2023, and not the billed date of 
service. Based on this information, we decided that Medicare rules for coverage of the drug testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services 
provided on January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service March 8, 
2023.   
You asked the Plan to pay for procedure code 88291. 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 88291 is 1. The MAI value for this code is 3. You billed 4 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 88291 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88291 billed for date of service March 8, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography. 
 
You asked the Plan to pre-approve a polysomnography. The Plan denied your request. The Plan says the sleep 
study is considered not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography studies may be indicated 
for the conditions listed in the Medicare rules section of this letter. 
 
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 polysomnography. Our reviewer says 
that a polysomnography is not medically necessary. Our physician reviewer found you have a diagnosis of 
obstructive sleep apnea, and the previous polysomnogram was in 2009. You have been on CPAP, but are 
having difficulty tolerating the mask interface, and you would like to try an alternative mask. Our reviewer 
found that according to notes in the clinical visit, you are using the device at least 4 hours per day for 12 out of 
30 days, or 40%. The apnea-hypopnea index (AHI) on CPAP was 3.7. Our physician reviewer found that it 
appears the issue here is tolerance of the mask interface. The CPAP is effective in controlling the sleep 
disordered breathing, so diagnostic polysomnography is not necessary. Our reviewer also found that it would 
be reasonable to address your intolerance of the interface. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral surgery provided on December 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered by Medicare. 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, 
the oral surgery is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the oral surgery provided on December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection panel provided on February 6, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Centers for Disease Control and Prevention (CDC) remarks that an onychomycosis infection may be diagnosed through visual inspection, questioning the patient on their symptoms, or a fungal culture. 
The CDC states "to confirm the diagnosis, the healthcare 
provider might collect a nail clipping to look at under a microscope or to send to a laboratory for testing". No 
mention was made of molecular-based testing or PCR testing. The CDC also notes that the term 
"onychomycosis" is the technical term for a "fungal nail infection" (CDC, 2022). The requested fungal 
infection panel at issue in this case is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the fungal infection panel provided on February 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 26, 
2022, to March 8, 2022, 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 
diagnosis is clinically supported. The Plan denied your request. The Plan says the medical records did not 
support 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 with diagnosis code J18.9, defined as pneumonia, unspecified 
organism. 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 physician reviewer found that the enrollee had a computed tomography (CT) scan 
of the abdomen and pelvis which showed tiny bilateral pleural effusions with left basilar atelectasis. The 
documentation provided is insufficient to establish a diagnosis of pneumonia. Therefore, the diagnosis code at 
issue, J18.9, is not justified.   
 
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 the inpatient hospital services provided on February 26, 2022, to March 8, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services for date of service October 9, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that services should be billed with the correct 
diagnosis codes.  
 
We looked at the file and Medicare rules. Review of the file shows that these services were billed with other 
specified code when a specific code with laterality is available. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for the emergency room services for date of service October 9, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve FreeStyle Kit sensors.  
 
You asked the Plan to pre-approve the FreeStyle Kit sensors. You say that the enrollee has diabetes and has 
difficulty monitoring her home blood sugars due to the inability to manipulate the blood glucose monitoring 
mechanism. The Plan denied your request. The Plan says that the enrollee does not use insulin and have not had 
any hypoglycemic (low blood sugar) episodes. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Kit sensors. Our reviewer 
says that criteria for use of the CGM is medically necessary. Our physician reviewer found the enrollee has 
documentation that her blood glucose sugar is in the 500's. This is somewhat unusual with the current mix of 
medications, but it can happen. In addition, the enrollee is unable to use a glucometer well due to the enrollee's 
rheumatoid arthritis as documented by her rheumatoid medical doctor. 
 
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 FreeStyle Kit sensors have been met. Therefore, we decided that the Plan 
has to pre-approve FreeStyle Kit sensors.   
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy services provided from  
January 11, 2023, to February 7, 2023. 
 
You asked the Plan to reimburse you for the psychotherapy services. You say that this provider is a licensed 
psychologist. The Plan denied your request. The Plan says the services were rendered by a provider who is not 
under contract with the health Plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy services provided from January 11, 2023, to February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat MBBs are covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
She had one set of diagnostic MBBs. The records state that she had one day of pain relief. The percentage of 
pain relief is not documented. The criteria for coverage is not met and the services are not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat medial branch blocks (MBBs).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99222) provided on February 8, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable 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 payment for CPT code 99222 is not supported in the medical record. Specifically, the claim in this 
case was billed with an emergency room place of service (POS) 23. It is inappropriate to billed code 99222 
with POS 23. 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 services (99222) provided on 
February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on February 5, 2023, billed 
with Evaluation and Management (EM) codes 99223 and G8427. 
 You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid Place of 
Service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Practitioner services provided have not been met. This service was billed with POS code 21. 
The records show that the patient was registered as outpatient hospital, as such this claim was billed with an 
inappropriate POS. Therefore, we decided that the Plan does not have to pay for Practitioner services provided 
on February 5, 2023, billed with Evaluation and Management (EM) codes 99223 and G8427.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
bilateral knee pain due to osteoarthritis. The requested genicular nerve block is considered experimental in 
nature for the treatment of chronic knee pain. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the EKGs and ultrasound provided from 
November 16, 2022, to December 1, 2022. 
 
You asked the Plan to waive the coinsurance for the EKGs and ultrasound. You say that you already paid your 
copayments for these services 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 $30 
copayment for outpatient diagnostic tests and therapeutic services. Your contract with the Plan also clearly says that you must pay a $125 copayment for in-network radiological diagnostic tests. 
 
You have been asked to pay a $12.65, which is less than the standard $30 copayment for the EKG provided on 
November 16, 2022. You have also been asked to pay a $30 copayment for the EKG provided on November 
22, 2022. You have also been asked to pay a $125 copayment for the ultrasound provided on December 1, 
2022. These items/services fall within the outpatient diagnostic tests and therapeutic services benefit category.  
 
You have been asked to pay a total of $167.65 ($12.65 copayment + $30 copayment + $125 copayment = 
$167.65). 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 coinsurance for the EKGs and ultrasound provided from 
November 16, 2022, to December 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast reduction. 
 
You asked the Plan to pre-approve a breast reduction. You say that the enrollee needs this reduction. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast reduction. Our reviewer says 
that this procedure is not medically necessary. Our reviewer found provided records in this case do not clarify 
that there is shoulder grooving to a depth greater than 1 cm with skin irritation or darkening by supporting 
garment (bra strap). Records do not clarify that the macromastia is not due to an active endocrine, 
pharmaceutical or metabolic process as required by the local coverage determination. 
 
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 breast reduction have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a breast reduction.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 22, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on September 22, 2022.