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

We decided that the Plan does not have to provide two routine transportation trips that are greater than 50 miles of driving distance.
You asked the Plan to provide additional routine mileage. You say that this transportation is necessary for you to get to your appointment. The Plan denied your request. The Plan says the location requested exceeds the Plan's routine transportation limit of 50 miles. Each one-way trip must not exceed 50 miles of driving distance in order to be eligible for coverage.
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 Plan's coverage rules apply in this
case. The Plan covers routine transportation to or from Plan-approved locations within 50 miles of driving
distance.
We looked at your request, the records in the case file, and the rules. The requested location is greater than 50
miles away. Based on this information, we decided that the Plan's rules for coverage of routine transportation
have not been met. Therefore, we decided that the Plan does not have to provide two routine transportation
trips that are greater than 50 miles of driving distance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81404, 81407, 81408) provided to the enrollee on February 16, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file shows that the enrollee had cardiovascular risk assessment testing on February 16, 2021. Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81404, 81407, 81408) provided to the enrollee on February 16, 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 trips. You say that you rely on transportation to make your medical appointments. The Plan denied your request. The Plan says the services are not covered.
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 Plan's coverage rules apply in this case. The Plan covers a maximum of 50 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The file shows that you have used 49 trips. This means that once 50 trips have been used, you will 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