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

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on January 
26, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care visits provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement of nails provided on January 
04, 2023. 
 
You asked the Plan to waive the copayment for debridement of nails. You say that you would like for these 
services to be reconsidered. 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 $44.43 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $44.43 copayment for debridement of nails. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. 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 debridement of nails provided on January 04, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional home physical therapy visit(s) 
(G0151 x 10). 
 You asked the Plan to pre-approve home health services. You say that the services are medically 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 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten (10) additional home physical therapy visit(s) (G0151 x 10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service July 11, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support payment. The Plan denied 
your request. The Plan says the billed code is not supported by the medical records. 
 
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 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 99223. Our reviewer says that the medical records do 
not support payment of this code. Our reviewer found the patient is a 96-year-old male who was treated in the 
hospital on July 11, 2022, for seizure-like activity. Code 99233 was submitted but not supported by the 
provided documentation. The patient was described in the note from that date as sitting comfortably in chair, 
awake and alert. The history was focused and brief. Physical findings were documented but were also brief and 
focused, with improved mental status. The patient was stable on Keppra and electroencephalogram (EEG) 
report was pending. The documentation did not contain a detailed history or physical and did not show 
evidence of medical decision-making of high complexity on July 11, 2022. 
 
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 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two motors (E2311). 
 
You asked the Plan to pre-approve an electrical connection between the wheelchair controller and two motors 
(E2311). You say that the enrollee is diagnosed with spinal cord compression and spinal stenosis. The need a 
wheelchair to be able to get around to provide for themselves. The Plan denied your request. The Plan says the 
electrical connection between the wheelchair controller and two motors cannot be covered. Although two 
power features are requested for this wheelchair (tilt and elevating leg rests), there is not a medical need to 
control these power options through the joystick. Member's upper limb strength and function are adequate for 
the member to be able to control the power options using their own switches which are included in the 
allowance of these power options. The plan approved a power wheelchair and other accessories (K0856, 
E2361, E1002, E1012). 
 
The Plan follows Medicare rules. Medicare rules say that code E2311 is only covered when needed to control 
two or more motors from a single interface. 
 
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 an electrical connection between the 
wheelchair controller and two motors (E2311). Our reviewer says that an electrical connection between the 
wheelchair controller and two motors (E2311) is not medically necessary. Our physician reviewer found An 
expandable controller is an electronic system that is capable of accommodating one or more additional features 
and can operate 3 or more powered seating options.  An attendant control is one which allows a caregiver to 
drive the wheelchair instead of the member.  An attendant control is usually mounted on one of the rear canes 
of the WC.  It is usually limited to proportional control devices, usually a joystick. The requested electrical 
accessories are not medically necessary as the member does have use of the upper extremity and can operate 
and control the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical connection between the wheelchair controller and two motors 
(E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical 
connection between the wheelchair controller and two motors (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99236 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for code 99236. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says the billed code is not supported. 
 
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 99236 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and 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 presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit.  
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 99236. Our reviewer says that code 99236 is not 
supported by the medical record. Our reviewer found the patient is a 91-year-old female who was treated in the 
hospital on June 2, 2022, for headache, dizziness, and weakness which resolved on arrival. Code 99236 was 
submitted but not supported by the provided documentation. Documentation revealed the patient's labs were 
unremarkable. Beta-blocker was stopped. The patient was described in the note from that date as 
asymptomatic. The history was focused and brief. Physical findings were documented but were also brief and 
focused. The patient was stable. The documentation did not contain a comprehensive history or physical and 
did not show evidence of medical decision-making of high complexity on June 2, 2022. 
 
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 99236 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99236 billed for date of service June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stereotactic body radiation therapy (SBRT) (77370 
and 77373). 
 
You asked the Plan to pre-approve the SBRT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is not unreasonable to consider prophylactic palliation in a patient with one enlarging site 
of disease, as a means to prolong disease control, prevent symptomatic progression, and delay the need for 
systemic therapy. However, the need of SBRT is not established versus a more standard 3D conformal radiation plan for palliation. SBRT has a not insignificant risk of severe or fatal toxicity (as reported in the 
SABR-COMET and other studies) such that with a goal of palliation, SBRT is not considered standard 
practice. Our physician reviewer's decision is therefore unfavorable as the treatment would not be furnished in 
accordance with accepted standards 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 the SBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the stereotactic body radiation therapy (SBRT) (77370 and 77373).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a liver transplant listing. 
 
You asked the Plan to pre-approve a liver transplant listing. You say that a liver transplant is medically 
necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a liver transplant listing. Our reviewer 
says that a liver transplant listing is considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has hepatocellular carcinoma.  The record indicates that 
the enrollee was deemed a candidate for liver transplantation.  The record indicates that the enrollee is 
undergoing continued care by the transplant program. The record provided is sufficient to establish the medical 
necessity and reasonableness, as defined by Medicare rules, of remaining on the transplant list. 
 
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 liver transplant listing have been met. Therefore, we decided that the Plan has 
to pre-approve a liver transplant listing.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair from an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an ultralightweight manual wheelchair from an OON provider. You say that 
there are no in-network providers within a reasonable distance to this patient who can provide an 
ultralightweight manual wheelchair. You say that without this wheelchair the enrollee is at risk of mortality and 
her condition will continue to decline. The Plan denied your request. The Plan says the items being requested 
are available from an in-network provider who is only 10 miles from the enrollee's home. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from the enrollees home who can provide an ultralightweight 
manual wheelchair. Under Medicare rules, this means that contract providers are accessible to the enrollee. 
Therefore, we decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair from 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is 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 ILR. Our physician reviewer found 
there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollee's clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable loop recorder (ILR) (33285).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the requested use of Keytruda is FDA-approved for the enrollees diagnosis- in combination with 
lenvatinib, which the enrollee is taking with stable disease. The documentation supports that the requested drug 
is safe and effective and otherwise reasonable and necessary for this 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 the medication have been met. Therefore, we decided that the Plan has to pre-
approve Keytruda (J9271).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and a positioning belt/safety 
belt/pelvic strap (E0978). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), a harness (E2313) and a positioning belt/safety belt/pelvic strap 
(E0978).. You say that these accessories are medically necessary. The Plan denied your request. The Plan says 
the upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not 
medically necessary. They are necessary when there is a medical need to control power options though the 
joystick. The notes do not show a medical need to control the power options through the joystick. The power 
options can be controlled using their own switches. These switches can be made any size without asking for a 
separate request. A seat belt is already included with the power wheelchair. The Plan has approved a 
wheelchair and other accessories (K0861, E2361x2, E1007, E1012, E0955, E2622, E2620, K0040x2, E0956x2, 
E1028x5) 
 
The Plan follows Medicare rules. Medicare rules say that code E2311 is only covered when needed to control 
two or more motors from a single interface.  The harness (E2313) is part of code E2311 and would only be 
coverable if code E2311 is covered. Code E0978 is covered if you have weak upper body muscles, upper body 
instability or muscle spasticity which requires use of this item for proper positioning. 
 
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 an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), a harness (E2313) and a 
positioning belt/safety belt/pelvic strap (E0978).. Our reviewer says that the requested electrical accessories are 
not medically necessary. Our physician reviewer found you do does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and a positioning belt/safety belt/pelvic strap (E0978). have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311), a harness (E2313) and a 
positioning belt/safety belt/pelvic strap (E0978).