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

 
We decided that the Plan does not have to reimburse you under the Wallet Benefit for hearing aid supplies 
provided on March 10, 2021, and December 10, 2021. 
 
You asked the Plan to reimburse you under the Wallet Benefit for hearing aid supplies. You say that the Wallet 
Benefit is designed to cover safety devices and without the hearing aid supplies the enrollee cannot safely 
navigate his environment. The Plan denied your request. The Plan says hearing aid supplies are not included 
under the 2021 Wallet Benefit. 
 
The Plan contract covers a supplemental Wallet Benefit. The Wallet Benefit does not provide coverage for 
hearing aid supplies.  
 
We looked at the file and the Plans rules. The file shows that the Wallet Benefit does not provide coverage for 
hearing supplies. Therefore, we decided that the Plan does not have to reimburse you under the Wallet Benefit 
for hearing aid supplies provided on March 10, 2021, and December 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria to transfer to 
LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care and 
does not need to transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation services provided to the enrollee on July 19, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says consultation codes are no longer reimbursable. 
 
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 99242 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99242 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
consultation services provided to the enrollee on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on 
November 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an assistant surgeon may not be paid for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 23415. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon 
services provided to the enrollee on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on December 14, 2021. 
 
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says this 
provider is non-participating with the Plan's vision network. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services when provided through the Plans vision network.  
 
We looked at the file and the Plan's rules. The file shows that the ophthalmological services were not provided 
by the Plans vision network provider. Based on this information, we decided that the Plan's rules for coverage 
of the ophthalmological services have not been met. Therefore, we decided that the Plan does not have to pay 
for ophthalmological services provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax for eyeglasses provided on November 1, 2021. 
 
You asked the Plan to pay for sales tax. The Plan denied your request. The Plan says sales tax is exclude from 
coverage and is not medical in nature. 
 
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 S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax 
for eyeglasses provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service October 14, 
2021. 
 
You asked the Plan to pay for procedure code 99239. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says the medical records do not support 
payment of this code. 
 
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.  Because the definition of this code includes a time requirement, the total minutes of hospital 
discharge day management must be documented in the medical record. In this case, the medical records from 
the date of service do not specify the number of minutes spent with the patient on hospital discharge 
management.  Without the number of minutes documented in the medical record, the billing of this particular 
code cannot be supported. Based on this information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99239 billed for date of service October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
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 Restasis.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hip replacement surgery performed in a hospital setting and 
billed with procedure code S2900 for dates of service August 3, 2021, and August 4, 2021. 
 
You asked the Plan to pay for code S2900. You say that this service was medically necessary and the inpatient 
hospitalization was authorized. The Plan denied your request. The Plan says you billed this surgery with an 
inappropriate code, so the hospital bill was recouped. 
 
The Plan must follow Medicare rules. Medicare rules say that codes with a Medicare Status Indicator of E are 
codes that are not recognized by Medicare but for which an alternate code for the same item or service may be 
available.  No payment is made under any Medicare system for codes with this status indicator. You billed the 
hip surgery with code S2900 on the claim.  This code has a status indicator of E, meaning that it cannot be paid 
by Medicare as billed.  There may be another code that is appropriate for Medicare billing.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code S2900 have not been met. Therefore, we decided that the Plan does not have to pay for hip 
replacement surgery performed in a hospital setting and billed with procedure code S2900 for dates of service 
August 3, 2021, and August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors. 
 
You asked the Plan to pre-approve these services. You say that you are out of sensors. The Plan denied your 
request. The Plan says the criteria for coverage 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 week 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 
continuous glucose monitor (CGM) sensors.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to approve additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you need transportation to your medical 
appointments. The Plan denied your request. The Plan says you have exhausted the 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 a maximum of 30 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 you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to approve additional routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service March 12, 
2020. 
 
You asked the Plan to pay for procedure code 97530. You say that due to an issue with the Plan's provider file, 
this claim could not be submitted earlier. The Plan denied your request. The Plan says the code billed is not 
appropriate 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 97530 is Therapeutic activities, direct (one on one) 
patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes. 
According to the medical records, the therapeutic services provided on the date of service in question were 
provided by an occupational therapy assistant in a home health setting.  A different CPT code should be used 
for this scenario. Code G0158 should be billed for services performed by a qualified occupational therapist 
assistant in the home health or hospice setting.  
We find that CPT code 97530 is not supported in the medical record because a different code should have been 
billed. Based on this information, we decided that Medicare rules for coverage of procedure code 97530 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 97530 billed for 
date of service March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on June 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) and Current 
Procedural Terminology (CPT) code 80307 (1 unit) remain not supported. 
 
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 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 drug testing services provided to the enrollee on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 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 laboratory services provided to the enrollee on August 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says this claim has not been billed in accordance 
with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray services provided on November 3, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the X-ray services. You say that the member cannot choose what radiologist 
reads their diagnostic tests. 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 X-ray services provided on November 3, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Therapeutic procedure provided on December 1, 2021 to 
December 31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Therapeutic procedure. You say that that prior authorization is not needed for 
this service. The Plan denied your request. The Plan says after review it was determined there is no coverage 
for this OON service. 
 
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 Therapeutic procedure provided on December 1, 
2021 to December 31, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical documentation submitted showing facet joint syndrome. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no indication for performing a radiofrequency ablation. There is no physical exam findings or 
imaging documented that support thoracic facet dysfunction. There have been no diagnostic medial branch 
blocks. The request 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion. 
 
You asked the Plan to pre-approve lumbar fusion.. You say that the records provided support the need for 
lumbar fusion surgery. The Plan denied your request. The Plan says the enrollee does not have an unstable 
spine. The Plan says that the enrollee does not have 6 weeks without using nicotine products before surgery. 
 
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 lumbar fusion.. Our reviewer says that 
lumbar fusion surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found without documentation of spinal instability and 6 weeks of smoking cessation, the medical 
appropriateness of a lumbar fusion surgery has not been demonstrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 16, 
2021, to August 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider is not certified with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that services must be 
provided by providers who are enrolled in the Medicare program. 
 
We find that procedure code S9122 has a Status Indicator of I on the Physician Fee Schedule. This means that  code S9122 is not valid for Medicare purposes. Additionally, the rendering provider does not participate with 
the Medicare program. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided 
to the enrollee from June 16, 2021, to August 27, 2021.