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

 
We decided that the Plan does not have to pay for revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when 
performed (37225) provided on July 8, 2021. 
 
You asked the Plan to pay for the endovascular revascularization. You say that this service is supported in the 
records. The Plan denied your request. The Plan says code 37225-RT is not supported by the medical records 
submitted. The operative report did not include documentation of open or percutaneous endovascular 
revascularization, or a unilateral femoral or popliteal artery(s) with atherectomy, includes angioplasty within 
the same vessel, when performed; therefore, this code cannot be verified. 
 
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 37225 is open or percutaneous endovascular 
revascularization, or a unilateral femoral or popliteal artery(s) with atherectomy, includes angioplasty within 
the same vessel, when performed. 
 
 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 revascularization. Our reviewer says that the service 
provided does not meet the criteria for coverage as billed. Our reviewer found that the procedure report does 
not include the criteria for this procedure, as multiple failed attempts of atherectomy and angioplasty are 
documented in the report. When a procedure is not fully performed, an appropriate modifier should be 
appended. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization have not been met. Therefore, we decided that the Plan does 
not have to pay for revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), 
unilateral; with atherectomy, includes angioplasty within the same vessel, when performed (37225) provided 
on July 8, 2021.
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. You say that the enrollee is not able to stand up or 
transfer by himself. The Plan denied your request. The Plan says custodial care is not covered. 
 
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 February 21, 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 from a nursing 
perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable skilled 
nursing service needs. Regarding rehabilitation services, the enrollee remained non-ambulatory and required a 
mechanical lift for transfers. He required varying assist with activities of daily living. There are no identifiable 
skilled therapy service needs. He does not require skilled nursing or therapy services on a daily basis. He does 
not meet 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says the member does 
not meet Medicare criteria for coverage. 
 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the member does not require the 
necessary services 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ClariFix procedure. 
 
You asked the Plan to pre-approve the ClariFix procedure. The Plan denied your request. The Plan says this 
procedure is considered investigational and experimental. 
 
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 ClariFix procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that intranasal cryoablation is not among the procedural options for treatment of 
vasomotor rhinitis. 
 
  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 ClariFix procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ClariFix procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit and inpatient 
hospital care provided from November 23, 2020, to November 27, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit and inpatient hospital care. You say 
that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 per day for days 1-7 of Inpatient hospital care and a $90 copayment for Emergency care. 
 
 You have been asked to pay a $1,000 copayment for four days of inpatient hospital care ($250 x 4 = $1,000) 
and a $90 copayment for an emergency room visit. 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 
an emergency room visit and inpatient hospital care provided from November 23, 2020, to November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on July 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit. 
The Plan denied your request. The Plan says the claim was denied due to a non-participating provider billing 
for unauthorized services. The Plan also says that the member does not have out of network benefits and the 
servicing provider is not a participating provider with the Plan. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on July 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgery to restore artery blood flow to the legs (CPT 
code 37221), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 services. physician reviewer found 
the record indicates that the enrollee has numbness and cramps at rest. The record indicates that the enrollee is 
able to walk distances and do aerobics. The duplex ultrasound results reported do not indicate the presence of a 
clinically significant obstructive lesion and no vascular imaging is provided. The requested service is not 
supported by the provided documentation as obstructive lesions have not been demonstrated. The elements of 
the coverage criteria are not satisfied. The requested service is not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgery to 
restore artery blood flow to the legs (CPT code 37221), for the enrollee.
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 this is medically necessary. The Plan denied your 
request. The Plan says care is routine in nature, and a team of providers is not needed. 
 
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 documentation does not support that the complexity of your nursing, medical and 
rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support the need for at least three hours a day/five days a week of therapy is 
needed. Therapy services can be provided at a lower 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 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 admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (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 the SNF admission 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the 
enrollee on June 7, 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 this code has a status indicator of B. 
 
In this case, the CPT Code Manual definition of code 99100 is "Anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)." 
 
We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status 
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment 
for other services not specified. 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 anesthesia services 
(procedure code 99100) provided to the enrollee on June 7, 2021.
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 the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you appear to have custodial needs. 
There are no required skilled nursing services identified. If skilled therapy services are needed, they can be 
provided at a lower level of care. The documentation does not support that it is medically reasonable and 
necessary to provide skilled services to you on a "daily basis" 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 the admission 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 23, 
2022. 
 
You asked the Plan to pre-approve SNF care after February 23, 2022.. You say that the requested admission to 
a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care after February 23, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (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 after February 23, 2022. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the 
documentation does not support that Keytruda is appropriate for the enrollee's condition. 
 
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 
enrollee does not meet the Medicare criteria for Keytruda. Our physician reviewer found the record does not 
indicate that the enrollee has microsatellite instability-high, mismatch repair deficient, or tumor mutational 
burden mutations/megabase. The Food & Drug Administration (FDA) has not stated that Keytruda is approved 
for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by 
clinical research appearing in a Medicare-approved medical journal. 
 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 use of Keytruda.
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 enrollee needs a SNF admission. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a SNF stay. 
 
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 that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve temazepam, 7.5 mg capsule. 
 
You asked the Plan to pre-approve temazepam. You say that the enrollee has done well in the past on this 
medication. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
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 pre-approve temazepam, 7.5 mg capsule.  
 Benefits for temazepam 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. 
 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.