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

 
We decided that the Plan does not have to pre-approve 10 additional rides. 
 
You asked the Plan to pre-approve the additional rides. You say that you need additional transportation 
provided because you do not have any family members to help you. The Plan denied your request. The Plan 
says this request for more transportation benefits goes beyond your benefit limit and is denied. 
 
 
 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 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request exhausts the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional rides.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laminectomy, facetectomy and foraminotomy (63048) 
provided on April 14, 2022. 
 
You asked the Plan to pay for the laminectomy, facetectomy and foraminotomy (63048). You say that 
procedure code 63048 denied in error and the claim should be reviewed for reprocessing. The Plan denied your 
request. The Plan says procedure code 63048 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 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 vertebral 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 does not support procedure code 63048. Our reviewer found that the 
medical records do not clearly document the use of procedure code 63048 and medical billing guidelines on the 
use of this procedure code were not followed. 
 
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 laminectomy, facetectomy and foraminotomy (63048) have not been met. 
Therefore, we decided that the Plan does not have to pay for the laminectomy, facetectomy and foraminotomy 
(63048) provided on April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
abdomen and pelvis, with contrast material(s), including non-contrast images (74174) and a computed 
tomographic angiography (CTA) of the chest (non-coronary), with contrast material(s), including non-contrast 
images (71275) to be rendered by the out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services can be performed by an  
in-network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services.  
 
 Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) 
of the abdomen and pelvis, with contrast material(s), including non-contrast images (74174) and a computed 
tomographic angiography (CTA) of the chest (non-coronary), with contrast material(s), including non-contrast 
images (71275) to be rendered by the out-of-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for tumor testing (81479) billed for date of service April 26, 2022. 
 
You asked the Plan to pay for tumor testing. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
The specimens for this test were collected on February 15, 2022, and April 14, 2022, rather than the billed date 
of service of April 26, 2022. 
 
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. Specifically, the Plan has not acknowledged nor addressed the exceptions to the 
applied rule. The testing in this case was performed on a live tumor sample which was collected in an 
outpatient hospital setting. It is likely that the second exception has been met in this case, which would mean 
that the correct date of service for this claim is the date the testing was performed: April 26, 2022. Therefore, 
we decided that the Plan has to pay for tumor testing (81479) billed for date of service April 26, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 21, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed. 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 January 21, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve branch block. 
 
You asked the Plan to pre-approve a genicular nerve branch block. You say that your right-knee replacement 
has caused nerve impingement and physical therapy has not solved the issue. You say that you understand 
genicular rhizotomy is considered experimental, but it could be life changing since you have tried everything 
else that has been offered. The Plan denied your request. The Plan says genicular nerve blocks and genicular 
nerve radiofrequency ablation are considered investigational and 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 genicular nerve branch block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that radiofrequency ablation of the genicular nerves in enrollees with pain 
after a total knee replacement is still being studied. It is considered experimental at this time. 
 
  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 genicular nerve branch block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular nerve branch block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device and related 
accessories. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has been compliant with 
conservative treatments. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
 We looked at the file and Medicare rules. The records provided do not show that the enrollee has lymphedema 
that extends into the chest, trunk, and/or abdomen. There is no record of a four-233k trial of a basic pump. 
Based on this information, we decided that Medicare rules for coverage of the requested device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression 
device and related accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of femoral fracture (27513) provided on 
April 16, 2022. 
 
You asked the Plan to pay for the open treatment of femoral fracture (27513). You say that the operative note 
supports the criteria for procedure code 27513. You say that the claim has been denied incorrectly and the 
claim should be reprocessed. The Plan denied your request. The Plan says the documentation does not support 
open reduction with internal fixation of femoral supracondylar or transcondylar fracture with intercondylar 
extension. 
 
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 27513 is open treatment of femoral supracondylar or 
transcondylar fracture with intercondylar extension, includes internal fixation, when performed. 
  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 open treatment of femoral fracture (27513). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the operative report does not include documentation of intercondylar extension. Therefore, the 
procedure 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 open treatment of femoral fracture (27513) have not been met. Therefore, 
we decided that the Plan does not have to pay for the open treatment of femoral fracture (27513) provided on 
April 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laminectomy, facetectomy, or foraminotomy (63053) 
provided on March 2, 2022. 
 
You asked the Plan to pay for the laminectomy, facetectomy, or foraminotomy (63053). You say that the 
records support the medical necessity for procedure code 63053. The Plan denied your request. The Plan says 
procedure code 63053 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 63053 is laminectomy, facetectomy, or foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or 
lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral segment (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, or foraminotomy (63053). 
Our reviewer says that the medical documentation does not support the use of procedure code 63053. Our 
reviewer found there was no documentation of 3 additional levels that were operated on. 
 
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 laminectomy, facetectomy, or foraminotomy (63053) have not been met. 
Therefore, we decided that the Plan does not have to pay for the laminectomy, facetectomy, or foraminotomy 
(63053) provided on March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 72052-59 and 72074 billed for date of service 
September 3, 2021. 
 
You asked the Plan to pay for codes 72052-59 and 72074. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says these codes are not supported in the medical 
record. 
 
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 72052-59 is x-ray of the cervical spine. The CPT Code 
Manual definition for code 72074 is x-ray of thoracic spine, minimum of 4 views.  
 
We find that CPT code 72052-59 is not supported in the medical record. Specifically, code 72052 is not 
supported because the only medical records you provided discuss x-ray of the thoracic spine.  You have 
provided no records showing an x-ray of the cervical spine.  For code 72074, in order to qualify for coverage, there must be 4 or more views of the thoracic spine documented.  According to the x-ray report, there was an 
anteroposterior (AP) view and two lateral views.  That is only a total of 3 views, not the required 4 or more 
needed to support the billing of code 72074. Based on this information, we decided that Medicare rules for 
coverage of codes 72052-59 and 72074 have not been met. Therefore, we decided that the Plan does not have 
to pay for codes 72052-59 and 72074 billed for date of service September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra wide/heavy duty commode chair. 
 
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 for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that if an E0168 commode is ordered and the beneficiary 
does not weigh more than 300 pounds, it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The records show that the enrollee does not weigh more than 300 
pounds. 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 an extra wide/heavy duty commode 
chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 26, 2021, to April 
29, 2021, as billed with Diagnosis Related Group (DRG) 637. 
 You asked the Plan to pay for inpatient care billed with DRG 637. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 637 is not 
appropriate as the diagnosis of myocardial infarction type 2 (I21.A1) is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 637. Our 
reviewer says that the diagnosis of myocardial infarction type 2 (I21.A1) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the medical record is without evidence of an 
imbalance between myocardial oxygen supply and demand unrelated to coronary thrombosis. There are no 
symptoms of acute myocardial ischemia, no new ischemic electrocardiogram (ECG) changes, no development 
of pathological Q waves, and no imaging with evidence of new loss of viable myocardium or new regional wall 
motion abnormality in a pattern consistent with an ischemic etiology. The review has determined that the 
medical records did not support the billing of myocardial infarction type 2 (I21.A1). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 637 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 26, 2021, to April 29, 2021, 
as billed with Diagnosis Related Group (DRG) 637.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested 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 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 CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 71250 billed for date of service May 16, 2022. 
 
You asked the Plan to pay for procedure code 71250. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says that the payment for code 71250 is bundled into the 
payment for code 71275. 
 
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. Specifically, the Plan states that an edit exists between codes 71250 and 71275, 
which were billed by the same facility for the same enrollee on the date in question. However, these services 
were billed on separate claims. Although the Plan provided the original claim for code 71275, the claim for 
code 71250 was not included in the file. Without this claim, we cannot verify that these services were provided 
by either the same provider or two providers within the same facility with the same specialty. The Plan's denial 
is not substantiated in this case. Therefore, we decided that the Plan has to pay for procedure code 71250 billed 
for date of service May 16, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 specimen collection and test (C9803, 87426), 
colonoscopy with biopsy (45380), surgical pathology (88305), and a non-covered item (A9270) provided from 
February 14, 2022, to February 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for COVID-19 specimen collection and test, colonoscopy with biopsy, surgical 
pathology, and a non-covered item. You say that you want the Plan to pay for the services. The Plan denied 
your request. The Plan says the provider is out-of-network. There is no referring provider involved in these 
services and the Plan did not authorize the services. 
 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 COVID-19 specimen collection and test (C9803, 
87426), colonoscopy with biopsy (45380), surgical pathology (88305), and a non-covered item (A9270) 
provided from February 14, 2022, to February 18, 2022, by an out-of-network (OON) provider.