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

 
We decided that the Plan does not have to pay for physician pathology services (88341, 88342 and 88360) 
billed for date of service December 23, 2021. 
 
You asked the Plan to pay for pathology services. You say that these services are supported as billed. The Plan 
denied your request. The Plan says these services were not billed in accordance with Medicare rules and are 
missing a necessary modifier for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88341, 88342 and 88360 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
pathology services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
pathology services (88341, 88342 and 88360) billed for date of service December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osseous surgery (D4260) to be provided by a 
network provider. 
 
You asked the Plan to pre-approve the osseous surgery (D4260). You say that the enrollee is experiencing 
severe pain. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pre-approve the 
osseous surgery (D4260) to be provided by a network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have to go for 
chemotherapy treatments and have a hard time getting transportation for treatment. The Plan denied your 
request. The Plan says you have exhausted your maximum benefit for the year. 
 
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 48 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 trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cast crowns (D2740) on tooth #19. 
 
You asked the Plan to pre-approve cast crowns (D2740) on tooth #19. You say that the tooth has been causing 
pain for 10 days and the tooth will disintegrate if the filling is removed. The Plan denied your request. The Plan 
says rules for Dental care have not been met. 
 
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 cast crowns 
(D2740) 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 cast crowns (D2740) on tooth #19. Our 
physician reviewer found the documentation submitted does not support the need for a crown restoration. A full 
crown would not be considered medically necessary in this instance. 
 
  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 cast crowns (D2740) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cast crowns (D2740) on tooth #19.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you are requesting 
an extension of transportation services because you used the trips you had. You also say that you have multiple 
medical conditions, and need multiple visits to doctors and treatments. The Plan denied your request. The Plan 
says you have used 32 one-way trips of the 32 one-way trips covered by the Plan for the year 2022. 
 
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 up to 32 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 non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown-porcelain fused high noble (D6750). 
 
You asked the Plan to pre-approve crown-porcelain fused high noble (D6750). You say that the dental services 
should be covered. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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 pre-approve 
crown-porcelain fused high noble (D6750).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261). 
 
You asked the Plan to pre-approve a CT colonography. The Plan denied your request. The Plan says this 
service 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 CT colonography. Our reviewer says 
that a CT colonography is not considered reasonable and necessary in this case. Our physician reviewer found 
the available records do not support that a virtual colonoscopy is medically necessary nor reasonable for the 
enrollee, and in fact, may serve only to delay their care and increase their risk in the event a colonic lesion 
requires removal. 
 
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 CT colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic (CT) colonography (74261).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says the enrollee 
has not completed the necessary evaluations. 
 
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records provided do show that the enrollee is mobile with a 
walker. There are no records to show the enrollee is unable to self-propel a manual wheelchair. An evaluation 
was not provided to show the enrollees home has adequate access for the operation of the power scooter. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81161, 81286, 81413, 81414, 81442, 81479) 
provided September 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of lab services (81161, 81286, 81413, 
81414, 81442, 81479) provided September 30, 2021. have been met. The plan has requested additional medical 
records from the provider. None were provided. Therefore, we decided that the Plan does not have to pay for 
lab services (81161, 81286, 81413, 81414, 81442, 81479) provided September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alimta and Paraplatin. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the 
enrollee is in a clinical trial. The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the requested drugs as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve Alimta and Paraplatin.
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 requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the criteria for LTACH not met. The 
enrollees needs are being met in the current acute setting. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where the enrollee is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 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 pre-approve a Freestyle Libre continuous glucose monitor sensor for 
the enrollee. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor sensor. You say that this is 
medically necessary. The Plan denied your request. The Plan says that the beneficiary is on a fixed dose of 
insulin and not adjusting their own insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 a Freestyle 
Libre continuous glucose monitor sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Freestyle Libre continuous glucose monitor sensor for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission.. You say that the admission is a medical necessity. The 
Plan denied your request. The Plan says we have confirmed that there are five in-network skilled nursing 
facilities all accepting new patients whose locations are within 22-52 minutes/23-46 miles of the enrollee's 
home, and all less than 75 minutes and 60 miles from the residence. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest and abdomen for the enrollee. 
 
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request does not meet guidelines for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that a CT 
scan is not medically reasonable and necessary. There is no EKG, plain chest x-ray or abdominal ultrasound 
reports in the chart. There are no labs. The amount of weight loss and duration have not been quantified. 
Absent further clinical information the medical necessity of requested CT of the chest abdomen and pelvis has 
not been established. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of a CT scan. 
 
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 CT scan have not been met. 
 
 
 
  
 Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest and abdomen for the 
enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 71046. 
 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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service May 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will be able to build up endurance to be able to 
handle chemotherapy. The Plan denied your request. The Plan says the intensive rehabilitation program is not 
medically necessary 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. Your 
medical status does not require intensive physician and nursing oversight in an IRF. You still require acute 
medical care management prior to transferring to a rehabilitation program. You continue to have elevated 
creatinine. While the patient may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not support that you require this therapy or can tolerate this 
therapy on an intensive IRF level. The documentation on 9/15/22 describes you as "groggy" and "tired." You 
have pain with sinus tachycardia. Furthermore, therapy notes indicate that your activity tolerance is limited by 
pain and fatigue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2020. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says Medicare denies a 
claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the 
date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an office visit was not filed until February 21, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
reader and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM reader and supplies. You say that the requested 
device and supplies are medically necessary to monitor the enrollee's diabetes The Plan denied your request. 
The Plan says the enrollee does not meet the rules for approval of this device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 perform blood 
glucose testing at least four times per day, 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 a Freestyle Libre 2 CGM reader and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) reader and supplies (K0553, K0554).