Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service June 29, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99070 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient or observation discharge (99239) 
provided on February 2, 2023, to February 7, 2023. 
 
You asked the Plan to pay for the hospital inpatient discharge. You say that the medical records support code 
99239 and should be paid. The Plan denied your request. The Plan says this service represents a hospital 
discharge day management of more than 30 minutes. The medical records submitted do not include discharge 
management note for the billed date of service. Therefore, code 99239 cannot be verified.  
 
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 inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We asked our physician 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 hospital inpatient discharge. Our reviewer found the 
records provided do not include the note associated with this care provided to help support the submission of 
this code. Therefore, the billed CPT code 99239 cannot be verified and is not supported in the provided 
documentation.  
 
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 hospital inpatient discharge have not been met. Therefore, we decided that 
the Plan does not have to pay for the hospital inpatient or observation discharge (99239) provided on February 
2, 2023, to February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service July 14, 
2023.  
 
You asked the Plan to pay for procedure code G0482. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0482 is bundled into payment for code 80307.  

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 G0482 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 G0482 billed for date of service July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure and the electrical stimulation 
provided on February 28, 2023. 
 
You asked the Plan to pay for the therapeutic procedure and the electrical stimulation. You say that you are a 
member of the Plan, and you feel you should not be responsible for this bill. 
 
The Plan denied your request. The Plan says the services are not covered. 
 
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 therapeutic procedure and the electrical stimulation provided on 
February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens and the deluxe frames provided on June 
13, 2023. 
 
You asked the Plan to pay for the progressive lens and the deluxe frames. You say that you have coverage for 
vision items, and you want to be reimbursed. The Plan denied your request. The Plan says the provider was 
out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by network providers. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens and the deluxe frames have 
not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens and the deluxe 
frames provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on August 4, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids were recommended by the Plan. 
The Plan denied your request. The Plan says the provider was out-of-network. 
 
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 received by network providers.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on August 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the abdomen (74183).

You asked the Plan to pre-approve the MRI. You say that the services should be covered as the enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the enrollee does not meet the clinical requirements to be approved.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

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 MRI. Our physician reviewer found that the available records do not support the medical appropriateness nor necessity for the subsequent requested abdominal magnetic resonance angiography under review.

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the abdomen (74183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyperbaric oxygen (HBO) treatment provided on June 
28, 2023.  
 
You asked the Plan to pay for the HBO treatment. You say that it is felt this was necessary treatment.  The Plan 
denied your request. The Plan says the criteria for HBO were not met in this case.  
 
The Plan follows Medicare rules. Medicare rules say that HBO therapy may be covered when used in addition 
to standard wound care.  
 
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 HBO treatment. Our reviewer says that 
the HBO treatment provided is not shown to be medically reasonable and necessary.  Our physician reviewer 
found the patient has type 2 diabetes mellitus with a foot ulcer status post debridement, amputation of 4th and 
5th digits, and hyperbaric oxygen therapy (HBOT) for 4 sessions. HBOT (fourth session) and home blood 
glucose testing was provided in this case. However, the provided documentation did not clearly describe how 
effective the first few sessions of HBOT had been to help support this fourth session or whether or not standard 
wound treatment was concurrently being utilized and planned for future treatment to help justify this request. 
Therefore, the HBOT will be considered not 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 the HBO treatment have not been met. Therefore, we decided that the Plan does 
not have to pay for the hyperbaric oxygen (HBO) treatment provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the mental health visits provided from 
April 28, 2023, and May 8, 2023. 
 
You asked the Plan to reduce the copayments for the mental health visits. You say that you disagree with the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for in-network mental health services.  
 
You have been asked to pay a $35 copayment for each mental health visit provided on April 28, 2023, and May 
8, 2023. This item/service falls within the outpatient mental health care benefit category. The total amount you 
owe is $70 ($35 copayment x 2 visits = $70).This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayments for the mental 
health visits provided from April 28, 2023, and May 8, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron Depot.

You asked the Plan to pre-approve Lupron Depot. 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.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Lupron Depot. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not have to pre-approve Lupron Depot.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion (22614), arthrodesis (22612, 22558), 
allograft (20939), autograft (20936), posterior segmentation (22842), and insertion of interbody biomechanical 
device (22853). 
 
You asked the Plan to pre-approve the lumbar fusion, arthrodesis, skin substitutes, posterior segmentation, and 
insertion of interbody biomechanical device. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is 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 the lumbar fusion, arthrodesis, skin 
substitutes, posterior segmentation, and insertion of interbody biomechanical device. Our reviewer says that the 
requested lumbar fusion, arthrodesis, skin substitutes, posterior segmentation, and insertion of interbody 
biomechanical device are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not indicate spinal instability, fracture or lesion. Therefore, 
the reviewer found that the requested services are 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 lumbar fusion, arthrodesis, skin substitutes, posterior segmentation, and 
insertion of interbody biomechanical device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion (22614), arthrodesis (22612, 22558), allograft (20939), autograft (20936), 
posterior segmentation (22842), and insertion of interbody biomechanical device (22853).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service 
March 29, 2023.  
 
You asked the Plan to pay for procedure codes 64493 and 64494. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2 
units for each code, exceeding the MUE. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
64493 and 64494 billed for date of service March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits.  

You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has received an episode of skilled nursing and has been educated and observed. The enrollee is stable without 
need for continued observation or education.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 8, 2023.

You asked the Plan to pay for procedure code 88341. You say that you disagree with the denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units.

In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 36 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually provided, were correctly coded, and were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical implant tooth #31 (D6010), custom fabricated 
abutment tooth #31 (D6057), and abutment supported porcelain/ceramic crown for tooth #31 (D6058). 
 
You asked the Plan to pre-approve custom fabricated abutment . You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutment tooth #31 (D6057).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer to, an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve transfer to an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says the in-network provider is able to provide the necessary services. Therefore, coverage criteria have not been met. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 transfer. Our reviewer says that the services are not medically necessary. Our physician reviewer found the appropriate treatment for you can effectively be continued at the current facility until more stable for re-consideration for transplant. There was no found medical advantage to transferring you at this time. Therefore, this transfer will be considered not medically necessary 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 transfer have not been met.  
 
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 transfer. Therefore, we decided that the Plan does not have to pre-approve transfer to an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the lumbosacral spine (72100), the x-ray 
exam of the cervical spine (72050), and the x-ray exam of the thoracic spine (72070) provided by a 
chiropractor on July 11, 2023. 
 
You asked the Plan to pay for the x-ray exam of the lumbosacral spine (72100), the x-ray exam of the cervical 
spine (72050), and the x-ray exam of the thoracic spine (72070). You say that the enrollee would like to 
continue their care at the current provider office. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-ray exam of the lumbosacral spine (72100), the x-ray exam of the 
cervical spine (72050), and the x-ray exam of the thoracic spine (72070) provided by a chiropractor on July 11, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 8, 2023. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service May 8, 2023.