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

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that you would like to appeal this drug for coverage. The
Plan denied your request. The Plan says Pembrolizumab (Keytruda) is not being used for a medically accepted
indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
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 Keytruda. Our reviewer says that
Pembrolizumab (Keytruda) is not medically reasonable and necessary for the enrollee. Our physician reviewer
found the requested use of Pembrolizumab (Keytruda) is not food and drug administration (FDA) approved for
the enrollee's diagnosis. Our reviewer found that the use is not supported by one of the major drug compendia
or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical
journal. Our physician reviewer also found that the use is not listed as not indicated, not supported or not
recommended in any of the compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic therapeutic procedure services (CPT 97110 and CPT 97124) for the enrollee.

You asked the Plan to pre-approve the services. You say that you have received this treatment in the past, and it has been beneficial. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve chiropractic therapeutic procedure services (CPT 97110 and CPT 97124) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat sleep study.

You asked the Plan to pre-approve the study. You say that you have many health issues. The Plan denied your
request. The Plan says there are no comorbid medical conditions to qualify for the study.

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 study. Our reviewer says that the
requested study is not considered medically reasonable and necessary in this case. Our physician reviewer
found you stopped CPAP because of intolerance, and you now want to restart it. An attended polysomnogram
done showed a normal AHI of 3.8. Therefore, you do not have a diagnosis of sleep apnea. There were no problems 
with the previous test. A repeat test 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 the study have not been met. Therefore, we decided that the Plan does not have
to pre-approve a repeat sleep study.
Appeal type: Surgery
Decision: Unfavorable

 
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 Current Procedural Terminology (CPT) code 11102 and 17003 remain 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 the denied codes is: 
 
CPT 11102: 
 
tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion 
 
CPT 17003: 
 
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant 
lesions (eg, actinic keratoses) 
 
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 
procedure report documents CPT 11102 under assessment and plan; however, there is no documentation 
submitted of the procedure to confirm services were performed. For CPT 17003 to be allowable, the primary 
code CPT 17000 would have to be approved. Therefore, this code would not be reimbursed. 
 
We looked at this coder'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 dermatology services (CPT 11102 and CPT 17003) provided to the enrollee on October 12, 
2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285).

You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration
because ICD-10 codes are not meant to deny or modify accurately assigned evaluation and management codes.
The Plan denied your request. The Plan says the billed level of service for this Evaluation and Management
code was adjusted to one that is consistent with the information on the claim.

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 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 the emergency department visit. Our reviewer says that CPT
code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do not include documentation to validate that an Emergency department visit for the
evaluation and management of a patient, which requires these 3 key components within the constraints imposed
by the urgency of the patient's clinical condition and/or mental status: 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) are of high severity and pose an immediate significant threat to life or
physiologic function, 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 the emergency department visit have not been met. Therefore, we decided that
the Plan does not have to pay for the emergency department visit (99285).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no 
complex wound care or other SNF level skilled nursing need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or 
therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled 
nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopy services (CPT 31295, CPT 31296) provided to 
the enrollee on September 21, 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 these codes were not billed in accordance with the appropriate guidelines. 
 
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 the denied codes is: 
 
CPT 31295: 
 
Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g. balloon dilation), transnasal or 
via canine fossa 
 
CPT 31296: 
 
Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g. balloon dilation) 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
enrollee underwent a bilateral frontal sinuplasty and a bilateral maxillary sinuplasty (i.e. two different 
procedures on four locations). The provider has billed in such a way as to indicate that the enrollee underwent 
two frontal sinuplasties and two axillary sinuplasties. This is incorrect. To indicate that the procedure was 
performed bilaterally, the provider should submit each procedure code once, but with a 50 modifier. 
Furthermore, as two procedures were performed, the second procedure code should also be submitted with the 
51 modifier (CPT 31295.50, CPT 31296.50.51). The documentation does not support the codes as billed (CPT 
31295, CPT 31295, CPT 31296, CPT 31296). 

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 endoscopy services (CPT 31295, CPT 31296) provided to the enrollee on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve the CT of the heart with quantitative evaluation of coronary calcium. You 
say that the requested test is needed for mixed hyperlipidemia and is medically necessary. The Plan denied 
your request. The Plan says the type of test being requested is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that quantitative calcium scoring is not a covered service and 
will be denied as not medically necessary.  
 
The current procedural terminology (CPT) code request was 75571. The definition of this CPT code is 
Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium. 
Because this CPT code includes quantitative calcium scoring, it is not covered. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) of the heart with quantitative evaluation of 
coronary calcium.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found long term
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide
clinical services that are materially different than those of short-term acute care hospitals. The enrollee is
receiving acute hospital care, and acute care services have not been denied. The documentation does not
support that the enrollee in this case requires services at the LTACH that are not available at the acute care
hospital where she is currently receiving care. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

You asked the Plan to pre-approve IRF care. You say that IRF care is necessary to regain maximum 
functioning. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the 
patient 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. Finally, there is not a reasonable expectation that 
this patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an outpatient office visit and extractions. 
 
You asked the Plan to pre-approve the office visit and extractions. You say that these services are for a medical 
issue, and not a dental issue. You also say that the enrollee has cancer and needs to have her tooth removed in 
the back in order to do radiation. The Plan denied your request. The Plan says that the request for dental 
extraction is not covered under Medicare or the enrollee's health plan. 
 
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 the office visit and extractions. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee was diagnosed with a neoplasm of the right parotid gland for which 
she is to undergo radiation treatment. Our reviewer found that tooth #'s 30 and 31 are in the path of the 
radiation, and are to be extracted prior to the radiation due to the high risk of osteoradionecrosis if the 
extractions are done after the radiation. 
 
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 office visit and extractions have been met. Therefore, we decided that the 
Plan has to pre-approve an outpatient office visit and extractions.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable


You asked the Plan to pre-approve Capecitabine. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that that Medicare approved compendia list severe renal impairment 
with creatinine clearance less then 30ml/min as a contraindication to the use of this drug. 
 
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 Capecitabine. Our reviewer says that 
Capecitabine is medically reasonable and necessary for the enrollee. Capecitabine is indicated for the treatment 
of metastatic colorectal cancer. While severe renal impairment is listed as a contraindication to Capecitabine, 
the clinical records in the case file do not contain documentation of severe renal failure. Consequently, the 
plan's denial is not substantiated. Documentation supports that the requested drug is safe and effective and 
otherwise reasonable and necessary for this enrollee. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for Capecitabine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Capecitabine have been met. Therefore, we decided that the Plan has to pre-
approve Capecitabine for the enrollee.

We decided that the Plan has to pre-approve Capecitabine for the enrollee. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear medicine test.

You asked the Plan to pre-approve a nuclear medicine test. You say that you do not have a tumor and that the requested test is a screening tool. You say that you have dense breasts and that you have already tried two screenings using routine mammograms and automated breast ultrasounds, but that you want to use this new technology to make sure nothing is missed. The Plan denied your request. The Plan says the requested service is not covered by Medicare for screening of breast cancer in the enrollee's clinical condition.

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 a nuclear medicine test. Our reviewer says that a nuclear medicine test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have dense breasts, for which she has undergone breast cancer screening with both mammograms and ultrasounds. These tests have shown no evidence of malignancy. The enrollee has no reported breast complaints. Therefore, additional breast cancer screening tests are not shown to be 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 a nuclear medicine test have not been met. Therefore, we decided that the Plan does not have to pre-approve a nuclear medicine test.