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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 87150) provided on 
February 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is 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 (CPT code 87150) provided on February 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation for your 
appointment in Grand Rapids, MI. The Plan denied your request. The Plan says you are requesting an 
additional 23.5 miles for a total of 73.5 miles and your benefit only allows 50 miles. The Plan also 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 Plans coverage rules apply in this 
case. The Plan covers up to 24 one-way trips and each one-way trip must 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 Plans 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 additional Modivcare 
mileage (A0170).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis rendered on 
October 14, 2021. 
 
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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 77061 is not valid for Medicare purposes. 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 pay for the 
diagnostic digital breast tomosynthesis rendered on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (73030 and 73140) provided on 
November 2, 2021. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says radiology services are not covered when 
provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Radiology services are not 
covered when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the 
radiology services (73030 and 73140) provided on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 3, 2021. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
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 drug tests 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 drug testing provided on June 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided on 
January 31, 2022. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is 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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound (CPT code 76705) provided on January 
31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says a SNF 
admission is not medically necessary. 
 
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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective 
you received oral medications. You had stable vital signs. Your lungs were clear. Regarding rehabilitation 
services, you received physical therapy and occupational therapy. You were at a modified independent to 
supervision level for functional mobility including gait to 150 feet with a rolling walker. You required varying 
assist with activities of daily living. There are no identifiable skilled nursing service needs. There are 
identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily 
basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography, head or brain (70450) provided 
January 26, 2022. 
 
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date 
of service. Please reconsider for processing. The Plan denied your request. The Plan says unbundled services. 
 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 
70450-26 is a column II code to column I code 70496-26. 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, head or brain (70450) 
provided January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the frames (V2020), spherocylinder, 
trifocal, plano to plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens (V2303), anti-reflective coating 
(V2750), and sphere, trifocal, plano to plus or minus 4.00d, per lens (V2300) provided November 12, 2021. 
 
You asked the Plan to provide additional payment for the frames and anti-reflective lenses. You say that your 
eyewear should be covered. The Plan denied your request. The Plan says your routine eyewear allowance has 
been applied and no further payment from the Plan is due. 
 
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 up to a $150 allowance every 24 months. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that your $150 routine 
eyewear allowance was applied to the eyewear.  Therefore, we decided that the Plan does not have to provide 
additional payment for the frames (V2020), spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12-
2.00d cylinder, per lens (V2303), anti-reflective coating (V2750), and sphere, trifocal, plano to plus or minus 
4.00d, per lens (V2300) provided November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code 
70544) provided on February 9, 2022. 
 
You asked the Plan to pay for the MRA. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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 70553 
is a column II code to column I code 70544. 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 MRA, head; without contrast material(s) (CPT code 70544) 
provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve monitoring by anesthesia staff during upper endoscopy. 
 
You asked the Plan to pre-approve monitoring by anesthesia staff during upper endoscopy. The Plan denied 
your request. The Plan says monitoring by anesthesia staff during upper endoscopy does not meet the Plan's 
Medical Policy coverage criteria. 
 
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 monitoring by anesthesia staff during 
upper endoscopy. Our reviewer says that the requested monitoring by anesthesia staff during upper endoscopy 
is not considered medically reasonable and necessary in this case. Our physician reviewer found that the 
clinical records provided in this case showed that the enrollee has an ASA Grade Assessment 2 (indicates a 
patient with mild systemic disease). The enrollee has no significant PMH to warrant MAC. There was nothing 
in the enrollee's record indicating that it was medically necessary to have an anesthesiologist present during this 
procedure. The review has determined that the services at issue in this case were 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 monitoring by anesthesia staff during upper endoscopy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve monitoring by anesthesia staff during upper 
endoscopy.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the laminectomy, facetectomy and foraminotomy (63048) provided on 
September 16, 2021. 
 
You asked the Plan to pay for the laminectomy, facetectomy and foraminotomy (63048). You say that the 
operative report clearly documents the laminectomies were performed at all three levels. You say that this code 
was denied in error and you request payment for both units of code 63048. The Plan denied your request. The 
Plan says that procedure code 63048 is not supported by the medical records submitted and the remaining 
codes have been approved. 
 
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 63048 is laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 
each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary 
procedure).  
 
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 laminectomy, facetectomy and foraminotomy (63048). 
Our reviewer says that the documentation submitted was reviewed and does meet the criteria for coverage. Our 
reviewer found that the operative report documents the foramen at L2-3, L3-4 and L4-5 were decompressed 
using the air drill and diamond bur, as well as Kerrison punches. Therefore, 2 units of CPT code 63048 should 
be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 units of laminectomy, facetectomy and foraminotomy (63048) have been met. 
Therefore, we decided that the Plan has to pay for the laminectomy, facetectomy and foraminotomy (63048) 
provided on September 16, 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 cytopathology rendered on December 30, 2021. 
 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 procedure code 88112 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. In this case, we have confirmed that code 88112 
is a column II code 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 cytopathology rendered on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (CPT code 81479) 
provided on September 27, 2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that the claim should be paid. The 
Plan denied your request. The Plan says the services were not 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 pay for the GeneSight Psychotropic testing. Our 
physician reviewer found the case file contains a GeneSight Order Medical Necessity Documentation form, and 
the results of the GeneSight testing. The documentation is insufficient to support that the GeneSight genetic 
testing was medically reasonable and necessary for the enrollee in this case. 
 
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 GeneSight Psychotropic testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the GeneSight Psychotropic testing (CPT code 81479) provided on 
September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0482) 
provided on October 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 (CPT code(s): 80307 and G0482) provided on 
October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CPAP device (CPT code E0601) purchased on October 
15, 2021, from a provider not certified with Medicare. 
 
You asked the Plan to pay for the DME. You say that you spoke with the plan two months ago and the 
representative confirmed that due to the Phillips recall, the Plan made an exception and would cover the cost of the replacement. The Plan denied your request. The Plan says the DME was obtained from a provider who is 
not under contract with the health plan, is not certified for Medicare, and was not authorized with the plan. 
 
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. 
 
This provider is not certified with Medicare. Your 2021 EOC states, "while you can get your care from an out-
of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, we 
cannot pay a provider who has opted out of or been excluded or precluded from the Medicare Program. If you 
go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the 
services you receive. Check with your provider before receiving services to confirm that they are eligible to 
participate in Medicare." Therefore, we decided that the Plan does not have to pay for the CPAP device (CPT 
code E0601) purchased on October 15, 2021, from a provider not certified with Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerves. 
 
You asked the Plan to pre-approve the basivertebral nerve ablation. You say that it is felt that this is the 
appropriate treatment for the enrollee's condition. The Plan denied your request. The Plan says this is 
considered an experimental procedure at this time. 
 
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 basivertebral nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a female with chronic low back pain. She has tried physical 
therapy and epidural steroid injections. Her medication trials have included Tylenol, Celebrex and Percocet. 
This is an experimental/ investigational procedure. Therefore, the procedure is deemed 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 basivertebral nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (CPT code V5261) purchased on August 11, 
2021, from an out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider is not in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. Hearing aids are 
statutorily excluded from Medicare coverage. The enrollee has a limited benefit through network providers. The enrollee is responsible for all costs for hearing aids not purchased from the Plan's supplemental hearing 
provider. Per the enrollee's EOC, hearing aids are to be provided by the Plan's supplemental hearing provider. 
The enrollee is responsible for all costs for hearing aids not purchased from the Plan's supplemental hearing 
provider. Therefore, we decided that the Plan does not have to pay for the hearing aids (CPT code V5261) 
purchased on August 11, 2021, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on December 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
December 15, 2021.