Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of the permanent occipital nerve stimulator.
You asked the Plan to pre-approve implantation of the permanent occipital nerve stimulator. You say that the requested implantation of the permanent occipital nerve stimulator is medically necessary. The Plan denied your request. The Plan says the requested implantation of the permanent occipital nerve stimulator 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 implantation of the permanent occipital nerve stimulator. Our reviewer says that the requested implantation of the permanent occipital nerve stimulator is not medically necessary. Our physician reviewer found at the present time, based on current medical literature the proposed therapy would largely be considered to be experimental and investigational (and therefore not eligible for coverage via Medicare). The current use of occipital nerve stimulation (ONS) for chronic migraine is still limited in quantity and
remains inconclusive. Further study is needed of this technology and there is a need for further study is also required to ensure the safety and sustained efficacy of this treatment modality. There remains a need for studies to be undertaken of this technology with adequate patient/subject sizes with sufficient follow-up in order to permit conclusions. Ultimately, given the weakness of the clinical evidence on the efficacy and safety of ONS in the literature to date it is clear that further evidence from higher quality clinical trials with long term outcomes are required. Since scientific evidence does not permit conclusions concerning the effect of the technology on health outcomes the service would be classified as being experimental in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of the permanent occipital nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of the permanent occipital nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of codes 95910, 95885, and 95937.
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 95910 is nerve conduction studies; 7-8 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.
We asked our coder 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 these services. Our reviewer says that the submitted records do not support the billing of codes 95910, 95885, and 95937. Our coder reviewer found the medical records provided do not document that a limited needle electromyography with nerve conduction was performed. The medical records document that pedicle screw stimulations were performed which are not baseline nerve conduction studies, therefore this service cannot be verified. The medical records provided do not document that a nerve conduction study of 7-8 studies was performed. The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95908. The medical records submitted document Train of Four testing, which does not meet the coding definition of CPT 95937; therefore, this service cannot be verified. Also, there is no CPT code specific to Train of Four testing. It is inclusive to IONM. We looked at this coder'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 pay for the testing services rendered on June 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 21, 2020 billed with code 99053.
You asked the Plan to pay for the medical services as billed. You say that these services should be paid. The Plan denied your request. The Plan says it was determined that payment should be made for the emergency room evaluation and electrocardiogram; however, 99053 is not a payable 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 99053 is Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.
Code 99053 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this service is always bundled into payment for other services provided. Based on this information, we decided that Medicare rules for coverage of the medical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 21, 2020 billed with code 99053.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extraction provided on February 11, 2021.
You asked the Plan to pay for the extraction. You say that your tooth was broken and poking your tongue. The Plan denied your request. The Plan says the service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The file shows that you received a surgical extraction of erupted tooth #31. Although the Plan offers a dental benefit in excess of Medicare coverage, this service is not among those covered under this benefit. The file shows that the Plan based their denial of the service on the optional supplemental benefit package.
However, the records show that you were not enrolled in the option supplemental benefit package. Therefore, we decided that the Plan does not have to pay for the dental extraction provided on February 11, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography angiography (CTA) scan of the chest (noncoronary) (71275).
You asked the Plan to pre-approve CTA scan of the chest. You say that this request is medically necessary. The Plan denied your request. The Plan says that the criteria for the CTA scan have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CTA scan of the chest. Our reviewer says that the requested service is medically necessary and reasonable. Our physician reviewer found that you are a 74 year old male. CT chest was performed on January 2, 2021. for COVID workup and incidentally found an aortic aneurysm of 4.8 cm diameter. You do not use tobacco and have no associated symptoms. Blood pressure is under control. CTA chest (noncoronary) was requested. Currently guidelines by the ACC/AHA state that for aortic aneurysms of 4-5.4 cm in diameter should be surveyed via ultrasound or CT every 6-12 months. As this patient fits into this criteria having been more than 6 months since the prior imaging, it is reasonable to monitor this abnormality with CT at this time. This request for CTA chest will be considered 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 CTA scan of the chest have been met. Therefore, we decided that the Plan has to pre-approve computed tomography angiography (CTA) scan of the chest (noncoronary) (71275).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel surgery.

You asked the Plan to pre-approve carpal tunnel surgery. You say that this requested surgery is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested surgery 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 carpal tunnel surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 65-year-old female was being treated for carpal tunnel syndrome. She presented with right hand pain and numbness with weakness. Exam of the right wrist and hand reveals visible deformity and hypertrophy of bone at multiple joints of the hand. There are areas of point tenderness with arthritic deformity noted. There is tenderness at the carpometacarpal joint of the thumb. Tenderness is noted over the A1 pulley of the middle finger with a palpable triggering phenomena. Range of motion is full. There is decreased grasp, pinch and strength with apposition. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Surgical release is not supported by published, large-scale, long-term peer-reviewed literature without failure of conservative measures having been tried and failed. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for right carpal tunnel surgery 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 carpal tunnel surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system and upgraded electronics.
You asked the Plan to pre-approve a power seat elevation feature (E2300), expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311). You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says although there are three approved power options on the wheelchair there is not a medical need to control the power options through the joystick and the seat lift is never covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The power seat elevation system does not serve a purpose that is primarily medical in nature and is not covered by Medicare or the Plan. The record shows upper limb strength and function are adequate for the enrollee to control the power options using their own switches which are included in the allowance of the power options. Therefore, we decided that the Plan does not have to pre-approve power wheelchair power seat elevation system and upgraded electronics.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided from October 24, 2020, to October 30, 2020.You asked the Plan to pay for home infusion therapy. You say that this should be covered.The Plan denied your request. The Plan says this was not billed with a valid 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.We find that CPT code S9500 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided from October 24, 2020, to October 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says alternate settings should be reviewed.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for falling and encephalopathy. Medical problems are stable. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the ophthalmological services: medical examination and evaluation (92014) and frames and lenses (FRLNA) provided October 28, 2020.
You asked the Plan to provide additional payment for the eye exam and eyeglasses. You say that you believe you should have a $100 eyewear allowance and should be reimbursed in full for the eye exam. The Plan denied your request. The Plan says out-of-network coverage has been correctly applied to these services and no additional reimbursement is due.
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 eye exams up to $30 and eyeglasses up to $50 when provided by an out-of-network provider. We looked at the file and the Plan's rules. In this case you were provided vision services by an out-of-network provider. The Plan has provided coverage for the eye exam and eyeglasses in accordance with the Plan contract. Therefore, we decided that the Plan does not have to provide additional payment for the ophthalmological services: medical examination and evaluation (92014) and frames and lenses (FRLNA) provided October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.You asked the Plan to pre-approve a grab bar. You say that your father has fallen twice in the shower.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief genicular nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of this procedure in the setting of knee pain has not been demonstrated in the peer-reviewed literature.
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 this is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, the request is considered 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 Coolief genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that the services are medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet criteria for acute inpatient mental health treatment as you were not shown to be a danger to yourself or others. You were not experiencing any auditory or visual hallucinations. You are noted to
be cooperative and compliant with treatment while not showing any aggressive behaviors. 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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage foradditional supplemental transportation rides.You asked the Plan to provide coverage foradditional supplemental transportation rides. You say that you needadditional rides because you have a wheelchair and you usethe transportation benefit toget to your dialysis appointments, which you have5 times per week.The Plan denied your request. The Plan says there are no additional rides availableto non-primary care provider'slocations for the duration of thecontract year.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 Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-wayridesper yearto other health care related locations (such as to the pharmacy or specialist appointments).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 provide coverage foradditional supplemental transportation rides.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services (HCPCS G0299) provided to the enrollee from May 6, 2020 to May 29, 2020.

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 payment is not allowed because the claim has invalid data/missing data.

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 HCPCS code G0299 is "Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes." 

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation provided does not include all necessary data required my Medicare in order to be considered for reimbursement, therefore, this service cannot be verified.

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 pay for skilled nursing services (HCPCS G0299) provided to the enrollee from May 6, 2020 to May 29, 2020.