Persius/hicric huggingface dataset:
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 continued services. The Plan denied your request. The Plan says you no 
longer require daily skilled services. 
 
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. Continued SNF services beyond March 24, 2022, were requested. 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 continued services. Our physician reviewer found that you were admitted to the SNF 
after treatment in an acute hospital for a heart failure exacerbation and Covid-19 infection. As of the latest 
records available you were walking using a rolling walker with minimum assistance, were at contact guard to 
minimum assist for transfers, and were at moderate to maximum assist for most activities of daily living. You 
were reported to otherwise be medically stable on outpatient medications. The records do not document the 
need for intravenous medications, new tube feeding, or ostomy care or daily complex wound care. The records 
do not document that daily inpatient skilled therapy services continue to be indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aortography (75639) provided on September 21, 2021. 
 
You asked the Plan to pay for the aortography. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exits between CPT codes 75630 and 
93454.  
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, we have confirmed that code 75630 is a column II code to column I code 93454; however, 75630 
was billed with a modifier.  
 
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 aortography. Our reviewer says that CPT code 75630 
does not meet criteria for billing or reimbursement consideration. Our reviewer found per CPT 93454 "Catheter 
placement in coronary artery(s) for coronary angiography, including intraprocedural injections(s) for coronary 
angiography, imaging supervision and interpretation." This procedure would be inclusive to CPT 93454, 
documentation does not support modifier -59 as a distinct procedure from CPT 93454. 
 
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 aortography have not been met. Therefore, we decided that the Plan does 
not have to pay for the aortography (75639) provided on September 21, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug 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. 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 Keytruda. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with oligometastatic triple negative breast cancer that is PDL1+. In this case, the requested drug is 
not FDA-approved for the enrollee's condition. However, there is support for the requested drug in Medicare-
approved compendia specifically in the National Comprehensive Cancer Network. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral (37227). 
 
You asked the Plan to pre-approve the surgical procedure. You say that please consider approval for lower 
extremity angiogram with revascularization if needed to improve his symptoms and quality of life. The Plan 
denied your request. The Plan says the records do not support that the request is 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in his case the record indicates that the enrollee has leg pain. The record indicates 
that the enrollee has coronary artery disease and rheumatoid arthritis. The most recent CT angiogram in 
December 2021 shows 50% stenosis of external iliac arteries bilaterally, and 50% stenosis of the left popliteal 
artery. The record does not include arterial duplex recordings of ankle brachial indices. The record does not 
indicate the presence of an obstructive lesion impairing blood flow. The elements of the coverage criteria are 
not satisfied and the requested service cannot be recommended. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), unilateral (37227).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry (83789) provided on July 12, 2021. 
 
You asked the Plan to pay for the mass spectrometry. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 83789, 
80307 and G0480. 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, we have confirmed that code 83789 is a column II code to column I codes 80307 and G0480; 
however, 83789 was billed with a modifier.  
 
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 mass spectrometry. Our reviewer says that CPT code 
83789 does not meet criteria for billing or reimbursement consideration. Our reviewer found CMS does not 
cover validity testing when billed with urine drug tests.  Therefore, this service would not be covered, as it is an 
internal test for accuracy. 
 
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 mass spectrometry have not been met. Therefore, we decided that the Plan 
does not have to pay for mass spectrometry (83789) provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness, lactic acidosis, and metabolic encephalopathy. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to improve self-care and you do not have 
anyone home during the day. You say that you do not agree with the denial. The Plan denied your request. The 
Plan says continued care could be provided in an outpatient, skilled nursing facility or long-term care facility 
setting. 
 
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 that there are no complex nursing or rehabilitation needs. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You did not provide an argument with your appeal request. The 
Plan denied your request. The Plan says you do not meet IRF criteria, and your needs can be met in a less 
intensive setting. 
 
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 your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for coronary artery bypass grafting. Your medical problems are stable, and you have no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the patient was admitted for needed evaluations for 
dementia and behavior disturbance and possible urinary tract infection. He has made improvements while in 
the hospital, but more help and therapy is needed to get him better so that he can return home. He needs 
focused SNF care to get him well enough so he can be discharged to home safely. The Plan denied your 
request. The Plan says the patient does not require SNF care. 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the patient has no identifiable skilled nursing 
needs.  While there are skilled therapy needs, it is not necessary for these therapy services to be provided on a 
daily basis in an inpatient 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L3-4 hemilaminectomy. 
 
You asked the Plan to pre-approve the hemilaminectomy. You say that you would like reconsideration because 
the enrollee is in debilitating pain and has failed conservative treatment. The Plan denied your request. The 
Plan says the records do not include any recent imaging. 
 
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 hemilaminectomy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no recent imaging study showing severe compression of the nerve roots. 
 
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 hemilaminectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the L3-4 hemilaminectomy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Mohs surgery (17311 and 17312) provided on July 21, 2021. 
 
You asked the Plan to pay for Mohs surgery (17311 and 17312). You say that repair grafts and flaps are 
separately reportable per the National Correct Coding Initiative Policy Manual for Medicare Services. You say 
that the claim should be reprocessed to pay 17311 and 17312 because they are not inclusive to a flap. The Plan 
denied your request. The Plan says CPT code 17311, 17312 and pathology services CPT code 88305 must be 
reported by a single physician who performs both the surgery and pathologic examination of the specimen.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that a single physician performs 
both the Mohs surgery and pathologic examination of the specimen(s). 
 
We find that CPT code 17311 and 17312 is not supported in the medical record. Specifically, the Mohs surgery 
and biopsy must be reported by the same physician. Based on this information, we decided that Medicare rules 
for coverage of Mohs surgery (17311 and 17312) have not been met. Therefore, we decided that the Plan does 
not have to pay for Mohs surgery (17311 and 17312) provided on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee brace (L1851). 
 
You asked the Plan to pre-approve the knee brace. You say that you would like reconsideration because the 
requested knee brace is medically necessary. The Plan denied your request. The Plan says the enrollee has not 
had a recent injury or surgery to your knee and the notes do not show that your knee is unstable on exam. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthosis with adjustable knee joints is covered if 
the beneficiary has had recent injury to or a surgical procedure on the knee(s).  Knee orthoses are also covered 
for a beneficiary who is ambulatory and has knee instability. 
 
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 knee brace. Our reviewer says that 
the member does not meet LCD criteria for coverage of the requested knee brace. Our physician reviewer 
found there is no documentation that the enrollee has had a recent injury to or a surgical procedure on the 
knee(s) or that the enrollee has knee instability on physical examination. 
 
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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee brace (L1851).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 22, 
2021. 
 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on December 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Pembrolizumab (J9271). 
 
You asked the Plan to pre-approve the Pembrolizumab. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 Pembrolizumab. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not meet compendia 
guidelines for use. 
 
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 Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Pembrolizumab (J9271).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 13, 2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 
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, we have confirmed that code 93042 is a column II code to column I code 93010. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services 
provided to the enrollee on June 13, 2021.