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

We decided that the Plan does not have to pre-approve ten (10) additional miles of routine transportation trips.
You asked the Plan to pre-approve additional mileage. You say that you need an additional 10 miles for routine transportation trips to see your provider who is 58 miles away from your home. The Plan denied your request. The Plan says you have exceeded your benefit limit.
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 when each one-way does not exceed 50 miles of driving distance.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional miles of routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services (procedure code 99285) provided to the enrollee on April 29, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says medical records are still needed to support CPT 99285 on this 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. In this case, the CPT Code Manual definition of code 99285 is "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. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found to bill this level of emergency room visit, 3 of 3 key components must be met or exceeded. In this case, the history and exam meet the comprehensive level, but the medical decision-making was only of moderate complexity. The presenting problems meet moderate risk, the diagnostic procedures meet minimal risk, and management option meets the moderate level. Therefore, the correct code to report for this service is CPT 99284. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency services (procedure code 99285) provided to the enrollee on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation rendered on December 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. Billed procedure code 85060 (blood smear interpretation) has a PC/TC indicator of 8 and the file shows that the services were not rendered to a hospital inpatient.
Therefore, we decided that the Plan does not have to pay for the blood smear interpretation rendered on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of a computed tomography (CT) scan of the pelvis billed with code 72193.
You asked the Plan to pay for the billed code 72193. You say that the records support that payment should be made. The Plan denied your request. The Plan says this was not billed with the required modifier.
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 the billed
code 72193 is a column II code to column I code 74177. 74177 was billed by a provider of the same specialty in the same billing group. 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 interpretation of a computed tomography (CT) scan of the pelvis billed with code 72193.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray transportation (R0700) provided on March 10, 2021.
You asked the Plan to pay for x-ray transportation. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not separately payable from the enrollee's SNF stay.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident
receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, the technical
component representing the procedure itself, including any associated transportation and setup costs, is subject
to consolidated billing and must be included on the SNF's Part A bill for the resident's covered stay rather than
being billed separately under Part B.
We looked at the file and Medicare rules. The record shows that the enrollee was a skilled nursing facility
resident at the time of service, meaning this must be billed by the skilled nursing facility. Based on this
information, we decided that Medicare rules for coverage of x-ray transportation have not been met. Therefore,
we decided that the Plan does not have to pay for x-ray transportation (R0700) provided on March 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of an infusion pump.
You asked the Plan to pre-approve infusion pump. You say that this is needed to treat the enrollee's chronic pain despite conservative therapies and surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has an implanted spinal cord stimulator and bladder stimulator, and an infusion pump is contraindicated with other programmable devices.
The Plan follows Medicare rules. Medicare rules state that implantation of an infusion pump may be covered under some circumstances, but is contraindicated with other implanted programmable devices. 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 infusion pump. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested infusion pump. Our physician reviewer found an implantable infusion pump is covered when used to administer opioid drugs intrathecally or epidurally for treatment of severe chronic intractable pain in patients who have a life expectancy of at least 3 months, and who have proven unresponsiveness. However, implantation of an infusion pump is contraindicated in patients with other implanted programmable devices, since crosstalk between devices may inadvertently change the prescription.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infusion pump have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of an infusion pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported crown provided on April 7, 2021 and the bitewing x-ray and periodic oral evaluation provided on May 4, 2021.
You asked the Plan to pay for the custom fabricated abutment, abutment supported crown, bitewing x-ray and periodic oral evaluation. You say that the information provided at the time of enrollment was misleading and the coverage related to out-of-network providers is not reasonable. You say that finding the true coverage is impossible and you are requesting the out-of-network benefits described. The Plan denied your request. The Plan says the services are not covered.
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, out-of-network routine dental services are not among those covered under this benefit. Only the optional supplemental dental benefits are covered out-of-network. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported crown provided on April 7, 2021 and the bitewing x-ray and periodic oral evaluation provided on May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (R0070) provided on June 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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. In this case, we have confirmed that code R0070 is a column II code to column I code R0075. 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 services (R0070) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second adult routine physical screening received on July 20, 2021.
You asked the Plan to pay for the physical. You say that you were not advised that this was only covered once per year. The Plan denied your request. The Plan says only one physical is covered per year.
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.
The plan contract states that routine annual physicals are covered once per year. The test at issue in this appeal is the second annual physical for the 2021 calendar year. The same was previously received on January 7, 2021. Therefore, we decided that the Plan does not have to pay for a second adult routine physical screening received on July 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204, 99214) arthrocentesis, aspiration and/or injection (20610) methylprednisolone acetate injection, 80 mg (J1040) provided March 15, 2021 to March 17, 2021.
You asked the Plan to pay for the office visits. You say that you were on vacation and was in a lot of pain and you needed to cortisone injections. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99204, 99214) arthrocentesis, aspiration and/or injection (20610) methylprednisolone acetate injection, 80 mg (J1040) provided March 15, 2021 to March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3330) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that you need this root canal. The Plan denied 
your request. The Plan says root canal is not a covered dental service. 
 
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 root canal is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal 
(D3330) for tooth # 30.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378). 
 
You asked the Plan to pre-approve the outpatient service. You say that the enrollee is due for a screening 
colonoscopy. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a diagnostic colonoscopy is covered for certain 
indicated diagnosis codes. If a diagnosis code is not listed, then it is not considered medically reasonable or 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Specifically, the file shows that the requested service is 
not medically necessary for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-
approve a diagnostic colonoscopy (45378).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services coded as 75710-59 provided on 
March 23, 2021. 
 
You asked the Plan to pay for the angiography services. You say that you would like this claim reprocessed 
based on the medical documentation provided. The Plan denied your request. The Plan says the medical 
records do not support the billing of this code with the -59 modifier. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service. 
 
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 angiography services Our reviewer says 
that the medical records do not support the code as billed. Our physician reviewer found the medical records 
provided do not include sufficient documentation to validate that 75710 was performed as a distinct, separate 
service from CPT 37225 RT, which was performed on the same date of service.  As a result, CPT 75710 is 
inclusive to 37225 RT and no additional payment is due for this service. 
 
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 angiography services have not been met. Therefore, we decided that the 
Plan does not have to pay for the angiography services coded as 75710-59 provided on March 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiographic (ECG) rhythm report provided on January 22, 2021 billed with code 93042.
You asked the Plan to pay for the billed code 93042. You say that the records support all billed services on this claim. The Plan denied your request. The Plan says the visit and the chest x-ray evaluation was approved for payment. However, 93042 was not billed with a required modifier.
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 the billed code 93042 is a column II code in relation to column I code 93010. 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 electrocardiographic (ECG) rhythm report provided on January 22, 2021 billed with code 93042.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered screening.
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. The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not cover this test without a personal history of cancer. Therefore, we decided that the Plan does not have to pre-approve BRCA 1 and 2 testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records submitted do not indicate that the enrollee is in an approved clinical 
study. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is experimental. More research is needed to show safety and efficacy. Open 
decompression is the gold standard procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous image-guided lumbar decompression for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted special services received on March 24, 2021 by 
an out-of-network (OON) provider and the office visit and x-ray received on March 31, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the unlisted special services, the office visit, and the x-ray. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
received are not a covered benefit. 
 
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 unlisted special services received on March 24, 
2021 by an out-of-network (OON) provider and the office visit and x-ray received on March 31, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 2,
2021.
You asked the Plan to pay for the dental service. You say that you were told this service was denied. You say
that you pay for dental coverage. You also say that you are on a limited income. The Plan denied your request.
The Plan says limited oral evaluation is not listed as a covered service.
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 limited oral evaluation is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation (D0140) provided on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.