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

We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia, anxiolysis (D9230).

You asked the Plan to pre-approve the nitrous oxide/analgesia. You say that you are in pain and need your tooth extracted. The Plan denied your request. The Plan says the analgesia is not covered under your benefits.

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. 

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 inhalation of nitrous oxide/analgesia, anxiolysis (D9230).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional chiropractic visits.
You asked the Plan to pre-approve 3 additional chiropractic visits. You say that you are in pain and fear regressing. The Plan denied your request. The Plan says the 3 chiropractic visits which remain in dispute are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 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 pre-approve 3 additional chiropractic visits. Our reviewer says that the criteria for coverage of the 3 additional chiropractic visits in dispute have not been met. Our physician reviewer found the record indicates that the enrollee has received chiropractic care for low back pain and to establish a home exercise program. The record is insufficient to establish the need for ongoing 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 3 additional chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional chiropractic visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (11606) provided February 11, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 11606 is excision of a malignant lesion. 

We find that CPT code 11606 is not supported in the medical record. Specifically, the records did not include a pathology report to support the diagnosis. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (11606) provided February 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services represented by code 97163 provided on March 27, 2020.

You asked the Plan to pay for code 97163. 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 covered 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 97163 is Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for code 97163. Our reviewer says that the medical records do not support the billing of code 97163. Our reviewer found the documentation supports a home visit for this date of service. A Healthcare Common Procedure Coding System (HCPCS) code should be used to report this service. Therefore, CPT 97163 would not be covered. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 97163 have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services represented by code 97163 provided on March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder biomarker lab services (represented by procedure codes 0012M and 0013M) provided on February 18, 2021.
You asked the Plan to pay for the CxBladder biomarker lab services. You say that these services should be paid in full as they are medically necessary. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules explicitly state that CxBladder testing is not covered for any indication. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder biomarker lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the CxBladder biomarker lab services (represented by procedure codes 0012M and 0013M) provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 18, 2020.

You asked the Plan to pay for the lab services. You say that these services should be covered. The Plan denied your request. The Plan says these services cannot be substantiated. The Plan says that it has requested medical records and orders from the referring provider from you multiple times and there has been no response.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In addition, rules say that you must be able to produce the records and written orders for services rendered.

In this case, we find that you have not provided any records to substantiate payment of this claim despite multiple requests from the Plan. You have not provided the required documentation showing who ordered the lab services in question. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous sedation/analgesia (D9239) to be provided for a tooth extraction.

You asked the Plan to pre-approve the sedation/analgesia. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered by your dental benefit.

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.

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 intravenous sedation/analgesia (D9239) to be provided for a tooth extraction.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation of nerves innervating the sacroiliac joint (64625) provided on March 25, 2021
You asked the Plan to pay for the radiofrequency ablation of nerves innervating the sacroiliac joint (64625). You say that the radiofrequency ablation of nerves innervating the sacroiliac joint (64625) were medically necessary. The Plan denied your request. The Plan says the radiofrequency ablation of nerves innervating the sacroiliac joint (64625) were 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 pay for the radiofrequency ablation of nerves innervating the sacroiliac joint (64625). Our reviewer says that the radiofrequency ablation of nerves innervating the sacroiliac joint (64625) were not medically necessary. Our physician reviewer found this procedure is considered experimental/investigational due to the wide variation in efficacy reported in the peer review literature. Therefore, the request is deemed 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 radiofrequency ablation of nerves innervating the sacroiliac joint (64625) have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation of nerves innervating the sacroiliac joint (64625) provided on March 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid batteries provided on March 24, 2021.

You asked the Plan to pay for the hearing aid batteries. You say that the batteries are covered items and there is not a provider within 200 miles of your home. The Plan denied your request. The Plan says hearing aid accessories are not a covered benefit and this provider is not a contracted provider with your Plan.

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 Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that hearing aid accessories are not covered by the Plan but are available to buy at an additional cost. Therefore, we decided that the Plan does not have to pay for hearing aid batteries provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis and dental extractions.

You asked the Plan to pre-approve removal of torus mandibularis and dental extractions. You say that the records provided support the need for the services being requested. The Plan denied your request. The Plan says the enrollee does not have an enhanced dental benefit which covers the dental procedures in dispute.

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. 

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 removal of torus mandibularis and dental extractions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 25, 2020.

You asked the Plan to pay for the lab services. You say that these lab services should be covered. The Plan denied your request. The Plan says the Place of Service reported on the claim is not correct

Medicare rules say that lab services should be billed with the Place of Service where the specimen was collected from the patient. In this case, you billed with Place of Service 81, which would indicate that the lab itself collected the specimen. However, the medical records show that the patient's specimen was NOT collected at the lab, but by the patient's doctor. The patient's doctor then sent the sample to your lab for processing. Based on Medicare rules, you should have entered the Place of Service where the specimen was collected on the 1500 Claim Form. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional skilled nursing visits to be provided on the home health setting.
You asked the Plan to pre-approve the additional home health services. You say that it is felt this should be covered. The Plan denied your request. The Plan says no further skilled nursing visits are 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 the additional home health services. Our reviewer says that the requested home skilled nursing visits are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs (e.g. IVs, complex wound care, new ostomy). The enrollee has available and willing caregivers. There is no medical need for skilled nursing care in the home. 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 additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional skilled nursing visits to be provided on the home health setting.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional four home health skilled nursing visits.

You asked the Plan to pre-approve the additional home health services. You say that the enrollee needs this care. The Plan denied your request. The Plan says these 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 the additional home health services. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found the enrollee was started with home health care on 6/11/2021. Skilled nursing has provided congestive heart failure education and diet education. The enrollee does not have documented skilled nursing needs (e.g. IVs, complex wound care, new ostomy, multiple/frequent medication changes). There is no medical need for ongoing skilled nursing visits in the home.

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 additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional four home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says you do not meet the criteria for coverage.
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 assesses adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
three times per day or 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 a
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve one level of bilateral transforaminal epidural steroid injections
(2 injections). We decided that the Plan does not have to pre-approve an additional level of bilateral transforaminal epidural steroid injections (2 injections).
You asked the Plan to pre-approve 2 levels of bilateral transforaminal epidural steroid injections
(4 injections total). You say that the injections are medically necessary. The Plan says that the injections are not 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 bilateral transforaminal epidural steroid injections. Our reviewer says that one level of bilateral transforaminal epidural steroid injections are medically necessary. Our physician reviewer found that the request for 2 levels bilaterally exceeds utilization limits; only one level bilaterally would meet the criteria of the LCD. The request is medically reasonable and necessary for only one level bilaterally. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of one level of bilateral transforaminal epidural steroid injections (2 injections) have been met. Therefore, we decided that the Plan has to pre-approve one level of bilateral transforaminal epidural steroid injections (2 injections). We decided that the Plan does not have to pre-approve an additional level of bilateral transforaminal epidural steroid injections (2 injections).
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on December 1, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided on December 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services represented by code 63046 provided on December 22, 2020.

You asked the Plan to pay for code 63046. You say that the medical records support the billing of code 63046. The Plan denied your request. The Plan says the medical records do not support the billing of code 63046.

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 63046 is Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic. 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for code 63046. Our reviewer says that the medical records do not support the billing of code 63046. Our reviewer found the medical records submitted do not include sufficient documentation to validate that a thoracic laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [spinal or lateral recess stenosis]), for a single vertebral segment was performed December 22, 2020, therefore, this service cannot be verified and is not eligible for reimbursement.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 63046 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services represented by code 63046 provided on December 22, 2020.