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

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the records do not support that the enrollee has had 
any syncopal episodes. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found the provided documentation does not indicate that the enrollee has a 
history of syncope. Therefore, the reviewer found that the requested ILR procedure 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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thyroid imaging; with single or multiple uptake(s) 
(78014). 
 
You asked the Plan to pre-approve a nuclear medicine thyroid scan. You say that you disagree with the denial. 
The Plan denied your request. The Plan says an ultrasound is medically necessary to follow-up thyroid nodules. 
A nuclear medicine scan is not indicated for clinical hypothyroidism. 
 
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 nuclear medicine thyroid scan. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has hypothyroidism on Synthroid. Recent thyroid hormone 
testing revealed the enrollee as euthyroid with hormone treatment. It was reported that the enrollee has a 
history of thyroid nodules. A nuclear medicine thyroid scan was requested. However, there was no evidence 
provided of a recent unclear thyroid ultrasound report, equivocal needle biopsy, or abnormal thyroid hormones 
to help justify this secondary testing method. It appears a thyroid ultrasound is warranted rather than nuclear 
medicine study in this case. Therefore, this request for thyroid nuclear medicine scan will be considered not 
medically necessary at this time and based on the provided documentation. 
 
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 nuclear medicine thyroid scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve thyroid imaging; with single or multiple uptake(s) (78014).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee has no skilled nursing needs that require a SNF. 
 
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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
September 21, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that this was medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 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 psychiatric diagnostic evaluation (90791) 
provided on September 21, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve the genicular nerve ablation. You say that this is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental for your condition. 
 
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 the genicular nerve ablation. Our 
reviewer says that the requested genicular nerve ablation is not considered medically reasonable and necessary 
in this case. Our physician reviewer found this procedure is considered experimental. Therefore, the reviewer 
found that the requested genicular nerve ablation 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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on June 16, 2023. 
 
You asked the Plan to pay for physicians services. 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 physicians services 
provided on June 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the emergency room visit, and the x-
ray provided on June 13, 2023. 
 
You asked the Plan to increase the reimbursement for the emergency room visit and the x-ray. You say that you 
disagree with the reimbursement amount. The Plan denied your request. The Plan says you were reimbursed 
the correct amount. 
 
 
 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 $75 
copayment for emergency care. Your contract with the Plan also clearly says that you must pay 10% 
coinsurance for an out-of-network x-ray. 
 
You have been asked to pay a $75 copayment for the emergency room visit. The record shows you should only 
be reimbursed $118.55, which is the maximum allowable amount for the emergency room visit. This 
item/service falls within the emergency care 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.  
 
You have also been asked to pay $10.40, which is 10% coinsurance of the allowed amount for the x-ray. The 
record shows you should only be reimbursed $37.57, which is the maximum allowable amount for the x-ray. 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 increase the reimbursement for the emergency room visit, and the x-ray 
provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on January 3, 2023, billed 
with codes 81003, 87481, 87500, 87640, 87641, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on January 3, 2023, billed with codes 81003, 87481, 87500, 87640, 87641, 87653 and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the hand orthosis provided on February 6, 
2023 
 
You asked the Plan to waive the cost sharing for the hand orthosis. You say that you told the provider you did 
not need this brace and did not use it. 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. Your 
contract with the Plan says that there is a $525 deductible which applies to in-network durable medical 
equipment and related supplies. Your contract with the Plan also says that you must pay 20% coinsurance after 
meeting the deductible for in-network durable medical equipment and related supplies. 
 You have been asked to pay $260.97 towards the deductible. The item or service you asked the Plan to waive 
the cost sharing for falls within the durable medical equipment and related supplies benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $525 in-network deductible 
which applies to in-network durable medical equipment and related supplies. This cost sharing is a contractual 
obligation that had not been met at the time the hand orthosis was received on February 6, 2023. Therefore, we 
decided that the Plan does not have to waive the cost sharing for the hand orthosis provided on February 6, 
2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires pulmonary 
rehabilitation at a LTACH. The Plan denied your request. The Plan says the enrollee's medical needs are being 
met at the current acute hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it is not safe to leave the hospital at this time because the 
enrollee remains on high flow nasal cannula and needs to demonstrate improvement or stability. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic services provided on February 2, 2023. 
 
You asked the Plan to pay for the orthodontic services . You say that the services should be covered. The Plan 
denied your request. The Plan says these are not covered services. 
 
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. 
 
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 pay for the 
orthodontic services provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye examination, the frames, and the single vision 
lenses provided on June 20, 2023. 
 
You asked the Plan to pay for the routine eye examination, the frames, and the single vision lenses. You say 
that you contacted the plan and the provider and were advised about which services needed to be done. You say 
that you should be covered. The Plan denied your request. The Plan says the claim processed correctly, and you 
have been reimbursed for the services. Please note, claim 113467013200 is a duplicate from the original 
processing of claim 113436938800. This Plan addressed the processing of the original claim. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when one routine eye examination and $100 (combined in and out-of-
network) benefit towards the purchase and fitting of eyeglasses. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for the routine eye examination and paid 
$100 towards the eyewear which exhausted the benefit. Based on this information, we decided that the Plan's 
rules for coverage of the routine eye examination, the frames, and the single vision lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the routine eye examination, the frames, and the 
single vision lenses provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on May 20, 2023, billed with 
codes 87502, 87503, 87801, and 87150. 
 
You asked the Plan to pay for the billed testing. You say that specimens are received from providers who have 
performed biopsies. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. The panel testing was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage of the billed testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the panel testing provided on May 20, 2023, billed 
with codes 87502, 87503, 87801, and 87150.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204-25 billed for date of service July 27, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the code is not 
separately reimbursable. 
 
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 99204-25 is not supported. Modifier -25 is appended to evaluation and management 
(E&M) codes to identify services significantly separate from minor surgical and endoscopic procedures. CPT 
codes 95911 and 95886, billed with 99204 in this case, are not considered minor surgical or endoscopic 
procedures. There are also no code edits between code 99204 and the other billed codes. A modifier is not 
needed to bypass an edit.  The E&M code, 99204, is not payable as billed in this case. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99204-25 billed for date of service July 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thread carpal tunnel release surgery. 
 
You asked the Plan to pre-approve the surgical service. You say that this is medically necessary due to the 
enrollee's pain level. You say that the enrollee is unable to have the traditional carpal tunnel procedure done. 
You also say that this is necessary due to the ineffectiveness of previous procedures done in the past to alleviate 
the pain for the enrollee. The Plan denied your request. The Plan says this is considered experimental and 
therefore is not covered. 
 
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 the surgical service. Our reviewer says 
that the requested thread carpal tunnel release surgery is not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. Studies are supportive of 
the requested surgical technique; however, surgery overall is not supported until a clear trial and failure of 
conservative measures have been documented. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested thread carpal tunnel release surgery 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thread carpal tunnel release surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee has tried and failed topical steroids, and 
the requested medication is preferred due to the enrollee's cancer and radiation. The Plan denied your request. 
The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 Otezla.