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

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 
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 60 one-way transportation trips when each one-way trip does not exceed 75 miles. 
 
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 mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right radiofrequency ablation (RFA) to the sacroiliac 
(SI) joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says Medicare rules consider this an experimental procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. Based on this information, we decided that Medicare rules for coverage of RFA to the 
SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve right 
radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of 
computed tomography (76376) provided on August 17, 2021. 
 
You asked the Plan to pay for the 3D rendering with interpretation services. You say that you would like this 
claim reprocessed and approved for payment based on the submitted medical records. The Plan denied your 
request. The Plan says this service is not eligible for separate payment based on Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that three-dimensional imaging is medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course 
of the patient. 
 
In this case, the CPT Code Manual definition of code 76376 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation. 
 
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 for separate payment of the 3D rendering with 
interpretation services. Our reviewer says that the documentation does not support separate payment for the 
services as billed. Our physician reviewer found that the reports of the computed tomography (CT) of the neck 
and chest done on August 17, 2021, describe maximum intensity projection imaging and hence reconstruction.  
This is part of the procedure for each of these exams. In order for 3D rendering to be considered a separate 
code for reimbursement there must be an explanation of the reason that the additional 3D rendering is 
medically necessary to aid in the particular diagnosis. Also, the documentation must include that the 3D 
rendering was done on a separate workstation. These elements are not documented in the report. No separate 
payment can be made for these services as billed. 
 
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 3D rendering with interpretation services have not been met. Therefore, we 
decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of computed 
tomography (76376) provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the 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 the lab 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 lab services provided on December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 12, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the records support this service as billed. 
The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 
is a column II code to column I code 70496. 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 70450 billed for date of service February 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular embolization or occlusion (37244) provided on 
December 3, 2021. 
 
You asked the Plan to pay for the vascular embolization or occlusion (37244). You say that the physician notes 
show resuscitative endovascular balloon occlusion of the aorta placement in the right femoral artery. You say 
that the claim should be reprocessed for payment of CPT code 37244. The Plan denied your request. The Plan 
says procedure code 37244 is not supported by the medical records submitted. 
 
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 37244 is vascular embolization or occlusion, inclusive of 
all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary 
to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation. 
 
 
  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 vascular embolization or occlusion (37244). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found the operative report does not fully describe the procedure billed and this cannot be verified as 
performed. 
 
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 vascular embolization or occlusion (37244) have not been met. Therefore, 
we decided that the Plan does not have to pay for the vascular embolization or occlusion (37244) provided on 
December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the 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 the lab 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 lab services provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the 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 the lab 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 lab services provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing (87799 & 80197) provided on April 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 lab testing (87799 & 80197) provided on April 
11, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on January 26, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that there was no medical necessity to be 
transported to the hospital. You also say that you did not want to go especially with the possible coronavirus 
exposure as a consequence. The Plan denied your request. The Plan says since there was no transport provided, 
there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trigger point injection (20553) billed on April 19, 2021. 
 
You asked the Plan to pay for trigger point injection (20553). You say that if a sacroiliac joint injection is given 
without imaging guidance CPT code 20552 or 20553 is to be used. You say that CPT code 20553 is the most 
appropriate code for the procedure and payment should be released. The Plan denied your request. The Plan 
says there is a more appropriate CPT code for the service performed. 
 
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 20553 is injection(s); single or multiple trigger point(s), 3 
or more muscles. 
  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 trigger point injection (20553). Our reviewer says that the 
medical documentation does not support the use of code 20553. Our reviewer found an injection procedure was 
performed for the sacroiliac joint; however, no imaging guidance was performed. Since this is a single joint 
space with less than 3 muscles, the use of procedure code 20553 is not supported. There is a more appropriate 
code than what was billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trigger point injection (20553) have not been met. Therefore, we decided that 
the Plan does not have to pay for trigger point injection (20553) billed on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for this out-of-network provider. 
 
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 physical therapy provided on April 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on September 
3, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment is made for this code 
per Medicare rules. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 99100 provided on September 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from January 13, 2019, through 
January 16, 2019, as originally billed with diagnosis code N17.0 defined as acute kidney failure with tubular 
necrosis. 
 
You asked the Plan to pay for the inpatient hospital care. You say that you believe that the documentation 
supports payment for the services as they were originally billed with diagnosis N17.0 resulting in diagnosis-
related group (DRG) 073. The Plan denied your request. The Plan says that the documentation does not support 
payment for the hospital care as it was originally billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided a complete copy of medical records from 
the inpatient stay. Without these medical records that were presumably used to recalculate the DRG, we cannot 
review the Plans decision to change payment from DRG 073 to 074.  Therefore, we decided that the Plan has 
to pay for the inpatient hospital care provided from January 13, 2019, through January 16, 2019, as originally 
billed with diagnosis code N17.0 defined as acute kidney failure with tubular necrosis.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on December 3, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and 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 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 an office visit (99214) provided on December 3, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection, aflibercept, 1 mg (Eylea) 
provided from January 18, 2022, to April 5, 2022. 
 
You asked the Plan to waive the coinsurance for injection, aflibercept, 1 mg (Eylea). The Plan denied your 
request. The Plan says the cost share was applied correctly in accordance with the members benefits. 
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
You have been asked to pay a 20% coinsurance for injection, aflibercept, 1 mg (Eylea). The injection, 
aflibercept, 1 mg (Eylea) falls within the Medicare Part B Prescription Drugs 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 waive the coinsurance for injection, aflibercept, 1 mg (Eylea) provided from January 18, 2022, 
to April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip-femur orthosis (L1690) provided on March 3, 2022. 
 
You asked the Plan to pay for the hip-femur orthosis. You say that all necessary documentation has been 
provided for this claim to be processed. The Plan denied your request. The Plan says the documentation does 
not support payment for the services as billed based on Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records that have been submitted do not include documentation that the 
ordering provider discussed the need for the equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the hip-femur orthosis (L1690) provided on March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15734 billed on November 15, 2021. 
 
You asked the Plan to pay for procedure code 15734. You say that the claim is coded correctly with appropriate 
procedure and modifiers. You say that a review of the enclosed medical records will find the services were 
medically necessary. The Plan denied your request. The Plan says procedure code 15734 is not supported by 
the medical records submitted. 
 
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 15734 is muscle, myocutaneous, or fasciocutaneous flap; 
trunk. 
 
  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 procedure code 15734. Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not include documentation of a muscle, myocutaneous or fasciocutaneous flap. Therefore, 
this procedure cannot be verified. In addition, modifier XU cannot be verified, as this procedure is not 
supported by the operative report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 15734 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 15734 billed on November 15, 2021.