Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve radiofrequency ablations at two levels. We decided that the Plan 
does not have to pre-approve radiofrequency ablations at the third level.  
 
You asked the Plan to pre-approve radiofrequency ablations at two levels. You say that the services are 
necessary. The Plan says that based on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve radiofrequency ablations at two levels.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 radiofrequency ablations at two levels. 

Our reviewer says that the services are medically necessary. Our physician reviewer found the LCD limits 
these procedures to only 2 levels may be performed in one session. Therefore, only 2 levels are deemed 
medically reasonable and 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 radiofrequency ablations at two levels have been met. Therefore, we decided 
that the Plan has to pre-approve radiofrequency ablations at two levels.  
 
We also decided that the Plan does not have to pre-approve radiofrequency ablations at the third level. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 radiofrequency ablations at the third 
level. Our reviewer says that the service is not medically necessary. Our physician reviewer found the LCD 
limits these procedures to only 2 levels may be performed in one session. Therefore, only 2 levels are deemed 
medically reasonable and 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 radiofrequency ablations at the third level have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablations at the third level. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was noted to be medically 
stable for discharge from the hospital on October 14, 2021. He had no complaints of pain. His functional level 
does not require daily skilled therapy services. He has no skilled nursing needs and does not require skilled 
nursing on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on March 9, 2021.

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 services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 95822 (EEG, recording in coma or sleep only) and 95813
(EEG extended monitoring, 61-119 minutes). Code 95822 is a column II code with a modifier indicator of 1
when billed with column I code 95813. Code 95822 was not billed with an appropriate modifier to allow for
separate payment. Therefore, we decided that the Plan does not have to pay for the electroencephalogram
(EEG) rendered on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Optune electrical stimulation device used for cancer treatment (E0766).

You asked the Plan to pre-approve the Optune electrical stimulation device used for cancer treatment. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says medical studies have not proven that this therapy is helpful for the treatment of recurrent glioblastoma multiforme.

The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy will be denied as not reasonable and necessary for the treatment of recurrent GBM. 

We looked at the file and Medicare rules. In this case, the enrollee has been diagnosed with recurrent GBM which is not a medically-accepted indication for tumor treatment field therapy. Based on this information, we decided that Medicare rules for coverage of the Optune electrical stimulation device used for cancer treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve the Optune electrical stimulation device used for cancer treatment (E0766).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on January 22, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you did not self-administer any medications to yourself at any time during your care at the hospital. You say that any medications received were administered by nurse staff at the direction of doctor's orders and you should not be responsible for the charges. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
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 pay for the self-administered drugs provided on January 22, 2021.
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to a power wheelchair while a resident in a skilled nursing facility (SNF).
You asked the Plan to pre-approve power wheelchair repair. You say that you are blind and cannot get around without a wheelchair. The Plan denied your request. The Plan says the denial of authorization for this equipment repair is correct, because Medicare Part B does not covered durable medical equipment - and therefore does not cover repair of durable medical equipment - when the enrollee is residing at a skilled nursing facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B does not separately cover durable medical equipment (DME) when the enrollee is a resident in a skilled nursing facility.
We looked at the file and Medicare rules. Medicare does not separately cover repairs to your wheelchair while you are a resident in a skilled nursing facility (SNF). Based on this information, we decided that Medicare rules for coverage of power wheelchair repair have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs to a power wheelchair while a resident in a skilled nursing facility (SNF).
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency room evaluation provided on April 13, 2021.

You asked the Plan to pay for the emergency room evaluation. You say that this was a medically necessary service. The Plan denied your request. The Plan says that this was billed with a dental diagnosis which means it is not covered.

The Plan must follow Medicare rules. Medicare rules say that dental services are not covered. 

Review of the records shows that while the enrollee did have a dental condition, the treatment provided was for pain and infection, which are medical issues. The enrollee was not evaluated for the care/treatment of the teeth or supporting structures. There is no valid rationale to consider this an excluded dental service. Therefore, we decided that the Plan has to pay for the emergency room evaluation provided on April 13, 2021.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0427) provided on May 25, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $250 copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip.
You have been asked to pay a $250 copayment for the Medicare-covered ambulance service provided. 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 waive the copayment for the ambulance transportation service (A0427) provided on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain-ceramic crown, core buildup, and upper
partial denture.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.

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 crown and core buildup are not
among those covered under this benefit. The Plan convers one partial denture every five years and the file
shows that the enrollee previously received a partial denture on May 7, 2019 for which the Plan approved.

Therefore, we decided that the Plan does not have to pre-approve a porcelain-ceramic crown, core buildup, and upper partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care coded as 99233 provided on December 31, 2020.

You asked the Plan to pay for the inpatient hospital care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim is inconsistent with the place of treatment submitted.

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 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

We find that CPT code 99233 is not supported in the medical record. Specifically, the medical record does not support that these services were conducted on an in-person basis and were instead telehealth services. There is a more appropriate CPT code to be reported in this case. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care coded as 99233 provided on December 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF care.. You say that you are a fall risk and are on controlled medication for this issue. You say that you are not healing the way you were expected to and are progressing slowly. You say that you cannot do activities on your own and that more time is needed for healing. The Plan denied your request. The Plan says the enrollee does not have daily skilled complex nursing or therapy needs.e Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was treated for pain, and had clear lungs. The enrollee received therapy in the SNF. By the dates in question, the enrollee was at a contact guard to minimal assist level with functional mobility, including gait to short distances. The enrollee required varying assist with activities of daily living. The enrollee tolerated a regular diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care. have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning rendered on March 9, 2021.

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 code 99497.

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 99497 is advance care planning by other qualified health care professional, first 30 minutes. 

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 these services. Our reviewer says that the submitted records do not support the billing of code 99497. Our reviewer found the medical records provided do not include sufficient documentation to validate that 99497 was provided on March 9, 2021, therefore this service cannot be verified.

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 advance care planning rendered on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options and components.

You asked the Plan to pre-approve Group 3 power wheelchair with multiple power options. You say that you need this power wheelchair and accessories. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a Group 3 power wheelchair with multiple power options is necessary for individuals that require both power tilt and recline which you do not.

The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with multiple power options is only covered for beneficiaries who meet certain criteria. Medicare rules state that if a base power wheelchair is not covered, then related accessories will be denied. 

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 Group 3 power wheelchair with multiple power options. Our reviewer says that you do not meet the Medicare criteria for the requested power wheelchair. Our physician reviewer found while you may be able to safely operate a power mobility device and have a Group 3 neurologic diagnosis, the requested Group 3 power wheelchair with multiple power options exceeds your medical needs. The documentation does not reveal that you are at high risk for development of a pressure ulcer, utilize intermittent catheterization for bladder management, or need a power seating system to manage increased tone or spasticity; therefore, a power tilt/recline (E1007) is not medically necessary. There is no detailed upper extremity neuromuscular exam of all of your muscle groups or myotomes. The findings support that your functional ability should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary; therefore the request for a Group 3 power wheelchair with tile and recline and all related accessories is 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 Group 3 power wheelchair with multiple power options have not been met. Because the criteria for the base power wheelchair have not been met, the related accessories are also denied. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options and components.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placement (D6010), prefabricated abutment (D6056) and implant supported crown (D6065).
You asked the Plan to pre-approve the surgical implant placement (D6010), prefabricated abutment (D6056) and implant supported crown (D6065). The Plan denied your request. The Plan says the services are not covered 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 the surgical implant placement (D6010), prefabricated abutment (D6056) and implant supported crown (D6065).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection.
You asked the Plan to pre-approve lumbar epidural injection. You say that you are appealing with records. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this
request is for multiple levels of interlaminar injections in one session which is not covered.
The Plan follows Medicare rules. Medicare rules state that lumbar epidural injections may be covered under
certain conditions. The response to each epidural should be determined prior to determining the value of a
repeat epidural and the specific methods used for subsequent epidurals.
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 epidural injection. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested lumbar epidural injection. Our
physician reviewer found the enrollee's back pain radiates into both lower extremities and is worsened with
standing, and relieved by sitting. He utilizes a cane to ambulate. You have required interlaminar injections at
L3-4 and L4-5. Given the request for multiple levels of interlaminar injections in one session, criteria for
coverage are not met.
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 epidural injection have not been met. Therefore, we decided that the
Plan does not have to pre-approve a lumbar epidural injection.