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

 
We decided that the Plan has to pay for an office visit (99213) provided December 17, 2021. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that this service is non-covered because it was provided within 10 days 
from a surgical procedure. 
 
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. Specifically, no medical records were provided to demonstrate that this was a 
follow-up visit to the surgical procedure. It is not clear that these services were directly related to the surgical 
procedure from the provided documentation. Therefore, we decided that the Plan has to pay for an office visit 
(99213) provided December 17, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care visits. 
 
You asked the Plan to pre-approve home health. You say that you need therapy in order to heal properly. The 
Plan denied your request. The Plan says the denial of authorization for home health care is correct. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health. Our reviewer says that 
you do not meet the Medicare criteria for home health care. Our physician reviewer found you do not have 
documented, ongoing, home health occupational therapy needs. You appear to have reached a plateau in 
function. Skilled services are not required to establish a maintenance program or to prevent deterioration of 
your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health care visits.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for outpatient mental health services (90837) provided December 10, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the claim cannot be paid as billed. 
 
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's denial did not clearly articulate the reason for the denial. The plan did 
not reference the applicable Medicare coverage rules to support the denial. The plan cited the member 
handbook but provided no citation to the specific plan contract rules applied to this denial. Therefore, we 
decided that the Plan has to pay for outpatient mental health services (90837) provided December 10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99379) provided July 30, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is 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. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, the code billed has a status of "B" and payment is always bundled with another service. Based on 
this information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99379) provided July 30, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Continuous Airway Pressure (CPAP) Device and 
accessories (A4604, E0601, A7038) provided September 16, 2021. 
 
You asked the Plan to pay for the CPAP machine and accessories. You say that the device was medically 
necessary and the in-network provider was unable to help you. The Plan denied your request. The Plan says the 
CPAP was obtained from a provider that does not participate in the Medicare program. 
 
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 that 
does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for a 
Continuous Airway Pressure (CPAP) Device and accessories (A4604, E0601, A7038) provided September 16, 
2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the deep sedation/general anesthesia (D9222 and D9223). We 
decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7240).  
You asked the Plan to pre-approve the removal of an impacted tooth (D7240)  and deep sedation/general 
anesthesia (D9222 and D9223). You say that you need your wisdom tooth pulled and you would like to appeal 
these services. The Plan says that the removal of an impacted tooth is not covered under your benefit package. 
The Plan also says that the deep sedation/general anesthesia will not be necessary if the removal of an impacted 
tooth is not rendered. 
 
We decided that the Plan has to pre-approve the deep sedation/general anesthesia (D9222 and D9223).  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
The Plan contract lists deep sedation/general anesthesia (D9222 and D9223) as a covered benefit. There is no 
language in the Evidence of Coverage about main services being covered versus secondary services. You 
reasonably believed these services would be covered because they are listed as covered benefits. Therefore, we 
decided that the Plan has to pre-approve the deep sedation/general anesthesia (D9222 and D9223).  
 
We also decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7240). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of an impacted tooth (D7240). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88108 and 88112) provided on 
August 20, 2021. 
 
You asked the Plan to pay for codes 88108 and 88112. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that codes 
88108 and 88112 are column II codes to column I code 88173. 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 the laboratory services (88108 and 88112) 
provided on August 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of thigh fracture (27513-XU-RT) provided on 
February 26, 2021. 
 
You asked the Plan to pay for the treatment of thigh fracture. You say that you would like this claim 
reprocessed for payment based on the medical documentation supporting the services as billed. The Plan 
denied your request. The Plan says the billed code in question is inclusive to another billed code and will not be 
paid separately. 
 
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 27513 is open treatment of femoral supracondylar or 
transcondylar fracture with intercondylar extension, includes internal fixation, when performed. 
 
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 treatment of thigh fracture. Our reviewer says that the 
requested documentation does not support payment for the services as billed. Our reviewer found the operative 
report does not include documentation to confirm modifier XU unusual non-overlapping service which would 
be a distinct service that does not overlap the usual components of the main procedure. The operative report 
documents that "There was clear intra-articular and intercondylar extension of the fracture with significant 
comminution. The tibial component was released and removed without significant difficulty with the use of 
osteotomies. The femoral canal and tibial component were both appropriately cemented with standard 
cemented technique. The component were then impacted gently into place and held while the cement dried."  
Documentation does not support a service that does not overlap a revision of total knee arthoplasty. Therefore, 
this modifier cannot be verified. 
 
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 treatment of thigh fracture have not been met. Therefore, we decided that 
the Plan does not have to pay for the treatment of thigh fracture (27513-XU-RT) provided on February 26, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
November 13, 2021. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. 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 the Computed tomography (CT) scan (70450) provided on 
November 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year. 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orgovyx. 
 
You asked the Plan to pre-approve Orgovyx. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 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 Orgovyx.  
 
Benefits for Orgovyx 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
with intolerance or unsatisfactory response to an oral iron replacement. She has not tried and failed the Plan's 
required drugs, Infed and Venofer. The records do not show that the required drugs would be contraindicated or 
less effective; therefore, Injectafer is 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 Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Eliquis tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that the requested treatment is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Eliquis 
tablet.  
 Benefits for Eliquis 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vertebral corpectomy (63087) provided on August 18, 2021. 
 
You asked the Plan to pay for the vertebral corpectomy. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says the documentation does not 
support payment for the code 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. 
 
In this case, the CPT Code Manual definition of code 63087 is vertebral corpectomy (vertebral body resection), 
partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or 
nerve root(s), lower thoracic or lumbar; single segment. 
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 vertebral corpectomy. Our reviewer says that the 
documentation does not support the billed CPT code 63087. Our reviewer found that the operative report does 
not include enough information to verify all criteria have been met for this procedure.  Documentation does not 
describe amount of resection. Per CPT guidelines "For vertebral corpectomy, the term partial is used to 
describe removal of a substantial portion of the body of the vertebra. In the cervical spine, the amount of bone 
removed is defined as at least one half of vertebra body. In the thoracic and lumbar spine, the amount of bone 
removed is defined as at least one-third of the vertebral body." 
 
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 vertebral corpectomy have not been met. Based on this information, we 
decided that Medicare rules for coverage of the vertebral corpectomy have not been met. Therefore, we decided 
that the Plan does not have to pay for the vertebral corpectomy (63087) provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you were unaware that an authorization was 
needed, and the referring provider ordered the test. The Plan denied your request. The Plan says the rendering 
and referring providers are both out-of-network providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 5, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on September 20, 2021. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, the CPT Code Manual definition of code 83789 is Mass spectrometry and tandem mass 
spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen. We find that tests to confirm that a urine specimen is not adulterated 
is not separately billable. Therefore, we decided that the Plan does not have to pay for the Mass spectrometry 
and tandem mass spectrometry (83789) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for Outpatient surgery on August 11, 2021. 
 
You asked the Plan to waive the deductible for Outpatient surgery. You say that you believe that $110.49 is an 
excessive amount for you to be required to pay for this procedure. The Plan denied your request. The Plan says 
the claim was processed correctly according to the members Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient surgery. At the time this 
claim was processed, $0 of the $750 deductible had been met. The allowed amount of the claim is $110.49, 
resulting in a deductible amount of $110.49. 
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
Outpatient surgery.  
 This cost sharing is a contractual obligation that had not been met at the time Outpatient surgery was received 
on August 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for Outpatient 
surgery on August 11, 2021.