Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total thyroid lobectomy. 
 
You asked the Plan to pre-approve total thyroid lobectomy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 total thyroid lobectomy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a biopsy is recommended in this setting. Unnecessary surgeries can be avoided with a 
reassuring biopsy and frequent follow up. The lobectomy in this setting exceeds the enrollee's medical need at 
this time given the data presented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total thyroid lobectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve total thyroid lobectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim was underpaid. The Plan denied your 
request. The Plan says the testing is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by the billed code is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G upper extremity assistive device. 
 
You asked the Plan to pre-approve a MyoPro Motion G upper extremity assistive device. You say that the item 
is medically necessary. The Plan denied your request. The Plan says this item is experimental. 
 
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 a MyoPro Motion G upper extremity 
assistive device. Our reviewer says that the requested item is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the device is not necessary to meet the enrollee's 
functional needs. 
 
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 MyoPro Motion G upper extremity assistive device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G upper extremity assistive 
device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious disease testing provided on January 19, 2022. 
 
You asked the Plan to pay for infectious disease testing. You say that the enrollee's treating physician ordered 
this medically necessary testing. The Plan denied your request. The Plan says this testing was not billed with 
the appropriate coding.  
The Plan must follow Medicare rules. Medicare rules say that molecular panels for infectious disease pathogen 
identification must be billed in accordance with certain coding standards.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of infectious disease testing have not been met. 
Therefore, we decided that the Plan does not have to pay for infectious disease testing provided on January 19, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 pre-approve a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex 
device is experimental. More research is needed 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show evidence of failure of continuous positive airway pressure 
(CPAP) or bilateral positive airway pressure (BiPAP). 
 
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. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the patient 
has severe COPD.  However, there is no arterial blood gas (ABG) done while stable and awake documenting 
chronic CO2 retention.  If that were to be confirmed, the patient may benefit from BiPAP with AVAPS and 
backup rate during sleep. But Medicare does not cover a home ventilator when used as BiPAP.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 5, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service 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 July 26, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement between the laboratory and the dialysis facility, therefore these services must be paid separately. 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 July 26, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the air ambulance services. 
 
You asked the Plan to pre-approve the air ambulance services. You say that due to the enrollee's need for 
continuous medical management during transport, fixed-wing air ambulance, with medical personnel on board 
capable of monitoring the enrollee's condition and treating any emergencies that developed in route, is the only 
safe solution for transferring the enrollee. The Plan denied your request. The Plan says the Health Plan does not 
cover air ambulance transportation to a skilled nursing facility. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our physician reviewer found there is no specific clinical rationale for the requested air ambulance services. The 
documentation does not support that the enrollee suffers from an illness or injury that contraindicates 
transportation by any means other than ambulance. The documentation does not support that the enrollee's 
condition was such that the time needed to transport a patient by ground, or the instability of transportation by 
ground, posed a threat to the patient's survival or seriously endangered the patient's health. The documentation 
does not support that the transferring hospital/ did not have adequate facilities to provide the medical services 
needed by 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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the air ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #18. 
 
You asked the Plan to pre-approve the crown. You say that your tooth requires a crown as a root canal was just 
approved and completed. The Plan denied your request. The Plan says the treatment does not meet the clinical 
criteria for a crown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
 
 
 
 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 crown. Our reviewer says that the 
documentation provided does not meet the criteria for coverage of a crown restoration on tooth #18. Our 
physician reviewer found that tooth #18 exhibits significant bone loss including a bifurcation involvement, 
and the periodontal condition should be addressed to provide a better prognosis of tooth retention prior to 
placement of a crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2751) for tooth #18.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on July 13, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is an Emergency department visit for the 
evaluation and management of a patient, which requires these 3 key components within the constraints imposed 
by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the patient was not bleeding 
more than mildly from the laceration, and the workup showed she was otherwise stable. Therefore, without 
evidence of this presentation being of high complexity, the code, 99285 is not supported in the records. 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 emergency room services (99285) 
provided on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no notes 
from the doctor. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The submitted documentation does not contain medical records 
showing the ordering physicians intent that the testing be performed. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305-26 billed for date of service August 
12, 2022. 
 
You asked the Plan to pay for procedure code 88305-26. You say that this claim should be paid. 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 September 3, 2022. 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 88305-26 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88305-26 billed for date of service 
August 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs coded J3490 provided on July 26, 
2022. 
 
You asked the Plan to pay for the unclassified drugs. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
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 J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as a minor surgery procedure 27096 (Injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed). Code J3490 was not billed with an appropriate modifier to bypass the edit. This means payment for this service is 
included in payment for code 27096. Based on this information, we decided that Medicare rules for coverage of 
the unclassified drugs have not been met. Therefore, we decided that the Plan does not have to pay for the 
unclassified drugs coded J3490 provided on July 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot insert (L3000x2) and a man's shoe, oxford brace 
(L3225x2). 
 
You asked the Plan to pre-approve foot orthotics. You say that you were diagnosed with arthritis on a section 
of your toes, explaining the ongoing pain and stiffness. Your provider ordered a certain type of footwear and 
orthopedic pads for your shoes for ongoing care and your well-being. The price of this care is beyond your 
financial means, and you are requesting reconsideration of the denial. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot insert (L3000x2) and a man's 
shoe, oxford brace (L3225x2).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says that that there is no documentation of ongoing medical management 
requiring skilled nursing oversight. 
 
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 has not forwarded the materials that led them to making their denial 
decision. Our doctot found that there are no skilled nursing notes submitted to support the plan's stated reasons 
for denial. Therefore, we decided that the Plan has to pre-approve additional home health skilled nursing visits.  
 
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.