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

 
We decided that the Plan does not have to pay for digital hearing aid (V5261) for two ears, sales tax (S9999) 
and an extended warranty (99999) provided on May 8, 2022. 
 
You asked the Plan to pay for digital hearing aid (V5261) for two ears, sales tax (S9999) and an extended 
warranty (99999). You say that you were never told that you would not be able to go out-of-network and get 
refunded your $500. The Plan denied your request. The Plan says the provider is out-of-network, and 
authorization to utilize an out-of-network provider was not obtained. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use an in-network provider.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of digital hearing aid (V5261) for two ears, sales tax (S9999) and an extended warranty (99999) have 
not been met. Therefore, we decided that the Plan does not have to pay for digital hearing aid (V5261) for two 
ears, sales tax (S9999) and an extended warranty (99999) provided on May 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and mechanical traction therapy 
(97012) provided from July 13, 2022, to July 25, 2022. 
 
You asked the Plan to pay for the office visit and mechanical traction therapy. You say that you followed all of 
the necessary steps to make sure this would be covered. The Plan denied your request. The Plan says all 
services other than manual manipulation of the spine for treatment of subluxation of the spine are excluded 
when ordered or performed by a Doctor of Chiropractic. The Plan also says that you had no additional benefits 
for routine chiropractic services. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99213) and mechanical traction therapy (97012) provided 
from July 13, 2022, to July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 CGM system. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 enrollee does not require three or more daily doses of insulin and 
does not require treatment with a continuous subcutaneous insulin infusion pump. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Dexcom G6 CGM system.
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 when you signed up for this plan, you were 
told that you could see this provider using this transportation benefit. If you do not see this doctor, your health 
is at risk. The Plan denied your request. The Plan says you are requesting an additional 91 miles for a total of 
141 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 11, 2021, billed 
with codes 81408, 81407, 81439, and 81286. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 11, 2021, billed with codes 81408, 81407, 81439, and 81286.
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 admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support medical necessity for admission to an IRF. 
The enrollee has no medical acuity or complexity and no acute rehabilitation nursing needs for an IRF 
admission. While the enrollee would benefit from physical therapy and occupational therapy, her rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99239. 
 
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 99232 is a column II code to column I code 99239 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, the Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99232 
billed for date of service July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heel loop holders (code E0951) you received on August 
2, 2022. 
 
You asked the Plan to pay for the heel loop holders. You say that you did not receive these items. The Plan 
denied your request. The Plan says the heel loop holders are built into the wheelchair and the Plan confirmed 
with the provider that you did receive them built into the chair you received.  The Plan says that the provider 
did not bill appropriately for these heel loop holders. 
 
The Plan must follow Medicare rules. Medicare rules say that the right (RT) and left (LT) modifiers must be 
used when appropriate. If bilateral items are provided, the items should be billed as two separate line items 
with the RT modifier on one line and the LT modifier on the other. In this case, the provider confirmed that you 
received built-in heel loop holders, one for the left and one for the right side of the wheelchair. However, the 
provider failed to bill these items on two separate lines on the claim, and failed to bill with the required RT and 
LT modifiers.  Until the provider bills these items correctly, the Plan cannot be required to pay for them.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the heel loop holders have not been met. Therefore, we decided that the Plan does not have to pay 
for the heel loop holders (code E0951) you received on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral exam (D0120) 
provided on October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to an in-network dentist. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service Febraury 16, 2022, and 
June 15, 2022. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) and 
periodic oral exam (D0120) provided on October 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95865) and neuromuscular 
junction testing (95937) provided on December 8, 2021. 
 
You asked the Plan to pay for the needle electromyography and neuromuscular junction testing. You say that 
you would like this claim to be reviewed and processed towards payment. The Plan denied your request. The 
Plan says these services are not authorized because the procedure codes are not Medicare benefits for the 
diagnosis listed on the claim. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 needle electromyography and 
neuromuscular junction testing. Our physician reviewer found the enrollee underwent a parathyroidectomy. 
Services were provided in the intraoperative setting. Our reviewer found that the enrollee's diagnosis/condition 
is not one for which the LCD supports provision of EMG or single fiber EMG (95937). Our physician reviewer 
also found that this is not a condition/situation for which there is any indication in the LCD that the services 
under review were otherwise considered to have been reasonable and necessary at the time they were provided. 
 
 
 
 
 
 
 
 
 
 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 needle electromyography and neuromuscular junction testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the needle electromyography (95865) and 
neuromuscular junction testing (95937) provided on December 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled therapy needs. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs, custodial and intermittent, can, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inversion table. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested inversion table is not 
considered the standard of care for the treatment of neck and back pain. It is not as effective as standard 
treatment, based on the medical literature and submitted medical records. The services are 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 an inversion table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found Medicare does not cover a home ventilator when used as bilevel positive airway pressure 
(BiPAP). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on April 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the assisted living facility is responsible to 
obtain prior authorization. The Plan denied your request. The Plan says there is no authorization on file for the 
services provided. 
 
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 wound care services provided on April 21, 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 code 99205 billed for date of service April 27, 2022. 
 
You asked the Plan to pay for code 99205. You say that this code was billed correctly because this was the first 
time the patient saw this provider. The Plan denied your request. The Plan says code 99205 is not appropriate 
because the patient had already received services from this billing provider prior to April 27, 2022. 
 
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 99205 is Office or other outpatient visit for the 
evaluation and management of a new patient. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the records show that the 
patient was not a new patient to this billing provider. The records show that the patient was seen by this same 
billing provided on August 20, 2020.  This same provider billed codes 45378 and 43239 at that time.  Because 
the patient had been seen by this provider prior to April 27, 2022, billing for a new patient visit is not 
appropriate. Based on this information, we decided that Medicare rules for coverage of code 99205 have not been met. Therefore, we decided that the Plan does not have to pay for code 99205 billed for date of service 
April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacements (D4263 x 2), biological materials 
(D4265 x 2), a hemisection (including any root removal), not including root canal therapy (D3920), and 
surgical placement of an implant body: endosteal implants (D6010 x 2). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says these items/services are not covered under your 
contractual policy. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items and services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
bone replacements (D4263 x 2), biological materials (D4265 x 2), a hemisection (including any root removal), 
not including root canal therapy (D3920), and surgical placement of an implant body: endosteal implants 
(D6010 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an astigmatism-correcting intraocular lens (A-C IOL). 
 
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 covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve an astigmatism-
correcting intraocular lens (A-C IOL).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hospital discharge day management services (99239) 
provided on May 8, 2022. 
 
You asked the Plan to pay for procedure 99239. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not supported 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, the CPT Code Manual definition of code 99239 is Hospital discharge day management; more than 
30 minutes.  
We find that CPT code 99239 is not supported in the medical record. Specifically, code 99239 is a time-based 
code. To bill CPT code 99239, the documentation must note that more than thirty minutes was spent providing 
services to the enrollee on the day of discharge. There is no progress note for May 8, 2022, provided in this 
case for review. As such, the provided documentation does not support the billing of code 99239. Based on this 
information, we decided that Medicare rules for coverage of procedure 99239 have not been met. Therefore, we 
decided that the Plan does not have to pay for the Hospital discharge day management services (99239) 
provided on May 8, 2022.