Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional mileage for routine transportation. 
 
You asked the Plan to provide coverage for additional mileage for routine transportation. The Plan denied your 
request. The Plan says the service is a covered benefit, but the enrollees request will exceed benefit limits set 
in the subscriber agreement for routine transportation. The benefit allows up to 36 one-way trips, combined in 
and out-of-network, per calendar year but each one-way trip must not exceed 50 miles of driving distance. The 
member is requesting an additional 30 miles for a total of 80 miles. 
 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. 
 
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. Therefore, we decided that the 
Plan does not have to provide coverage for additional mileage for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is documented to have C1 
disease. Additionally, the areas of reflux in the saphenous veins bilaterally are relatively focal and barely reach 
the minimum degree of reflux to be considered significant.  Ablation of the great saphenous veins bilaterally 
would ablate what appears to be largely normal saphenous veins.  There is also a lack of clarity to the plan.  It 
appears that part of the plan is to perform at least 2 sessions of sclerotherapy on the left leg in the absence of 
varicose veins or tributary reflux on that side.  There is also a lack of clarity with respect to the duration of 
conservative treatment and unclear when she was prescribed 20-30 mmHg compression stockings. The criteria 
for coverage are not met and the services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met.  
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while the enrollee has a history of 
atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 11, 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, for 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 October 11, 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 July 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus diabetic test strips (A4253).  
You asked the Plan to pre-approve Accu-Chek Aviva Plus test strips. You say that the request is a medical 
necessity for you. The Plan denied your request. The Plan says rules for diabetic testing supplies have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Accu-Chek Aviva Plus test strips have not been met. Specifically, the requested item is a non-
preferred brand. The case record does not contain medical documentation that supports the medical necessity of 
the requested item. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus 
diabetic test strips (A4253).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 92960 provided on February 1, 
2022. 
 
You asked the Plan to pay for procedure codes 99291 and 92960. You say that the medical records support the 
billing of code 99291 or the billing of code 92960 with modifier 59. The Plan denied your request. The Plan 
says the medical records do not support the billing of code 99291 or the billing of code 92960 with modifier 59. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The definition of code 92960 is Cardioversion, 
elective, electrical conversion of arrhythmia; external. 
 
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 codes 99291 and 92960. Our reviewer says that the medical records do not support the billing of code 99291 or the billing of code 92960 with modifier 59. Our 
reviewer found the documentation submitted was reviewed and the medical records do not support the billing 
of code 99291. The medical record includes an evaluation and management service, however critical care 
evaluation and management service is not supported in the documentation. The report does not include 
documentation of critical care service provided, and time spent performing critical care services. Therefore, this 
procedure cannot be verified. 
 
CPT 92960 - The documentation submitted was reviewed and the medical records do not support the billing of 
code 92960 with modifier 59. The medical record does not include documentation of cardioversion procedure. 
The procedure report does not describe wires connected to sensor to a cardioversion machine, and quick low-
energy shocks delivered to restore a regular heart rhythm. The medical record includes an electrocardiograph 
report, which does not include cardioversion procedure. 
 
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 codes 99291 and 92960 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99291 and 92960 provided on February 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Omnipod. 
 
You asked the Plan to pre-approve Omnipod. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Omnipod.  
 
  Benefits for Omnipod may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erivedge. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Erivedge.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Morphine Sul tablets. 
 
You asked the Plan to pre-approve Morphine Sul tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Morphine Sul tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Morphine Sul tablets.  
 
Benefits for Morphine Sul tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 13, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 13, 2021.
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) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria are not met. 
 
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 you do not treat with insulin three 
or more times per day or use an insulin pump. 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 pre-approve 
a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve skilled nursing facility services. You say that the enrollee is not in a hospice 
program and is need of a SNF due to having a stroke. You say the enrollee lives alone and does not have 
anyone to help them The Plan denied your request. The Plan says a SNF admission is not medically necessary 
because the enrollee is enrolled in a hospice program. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
   
The enrollee ended Medicare Hospice benefits on November 8, 2022. The services will be provided before the 
end of that month. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extraction (D7140) provided on September 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that this service was for a dental emergency. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental extraction (D7140) provided on September 21, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nephrology care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON nephrology care. You say that you do not believe treatment is 
available with other providers. You said that you were not happy with the network provider you used before. 
The Plan denied your request. The Plan says services are available in-network. 
 
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 
nephrology care to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 July 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 enrollee does not have complex nursing or rehabilitation needs. Medically 
necessary care can be provided in a different level of care. 
 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 2, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 July 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve Livalo. The Plan denied your request. The Plan says this drug is not covered 
under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel release surgery, neuroplasty and/or 
transposition of the median nerve at the carpal tunnel (64721). 
 
 
You asked the Plan to pre-approve the carpal tunnel release surgery. You say that please reconsider the denial 
for bilateral carpal tunnel surgery. The Plan denied your request. The Plan says the enrollee does not meet 
medical necessity criteria because there is no documentation which indicates a trial of conservative treatment. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. The appeal note stated that the 
enrollee has tried nighttime splinting; however, it is not clear how long the enrollee has trialed this. 
Additionally, the documentation does not demonstrate failure of physical therapy or injection. Moreover, the exam does not provide any objective clinical findings to corroborate carpal tunnel pathology. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested carpal tunnel release surgery, neuroplasty 
and/or transposition of the median nerve at the carpal tunnel (CPT 64721), in this case, is 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve carpal tunnel release surgery, neuroplasty and/or transposition of the median 
nerve at the carpal tunnel (64721).