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

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested treatment is not considered medically 
necessary 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 the medication. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollees diagnosis because no PDL1 
provided. 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. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (J9271).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from March 25, 2023, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that you have acute clinical and functional status 
change thus would require assessment by skilled nursing/therapy however provider documents that you are no 
longer appropriate for SNF level of care; thus, the documentation does not show that you require daily skilled 
services on a inpatient basis in a SNF. 
 
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 the continuation of skilled nursing facility (SNF) care from March 25, 2023, forward.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that IMRT is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the service is not covered by Medicare or the Plan. The enrollee has a 
history of Kaposi's of the extremity. There is a documented rationale and some citations of weak evidence. The 
approach is outside the Plan's policy. ASTRO guidelines cite use of IMRT but list only a moderate level of 
evidence. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT can be considered medically necessary if treating the target (which is often 
convex/concave in shape) would otherwise unnecessarily result in treating a large area of the limb. IMRT is 
often used with limb (i.e., arm or leg) sarcomas, which is a more common situation than the enrollees Kaposis 
sarcoma of the feet. This case is somewhat challenging in that the doses used to treat Kaposis sarcoma are 
generally less than other sarcomas. Though regardless of the dose delivered, IMRT affords a benefit of 
delivering a more homogeneous dose delivery compared to what could be achieved with a plan of multiple 
electron fields, and while a plan of AP/PA fields would result in a uniform dose delivery (particularly if a water 
bath were used), this would not allow any normal tissue sparing. While there is not a comparison plan (3D 
conformal or electron versus IMRT), it is plausible that a non-IMRT plan would be unacceptable. It is plausible 
that IMRT would be needed to adequately cover the target while sparing the normal tissue of the foot. Thus, the 
decision is this case is favorable as IMRT would be furnished in accordance with accepted standards of practice 
and not being used for routine treatment of skin Kaposis sarcoma (which generally does not require IMRT as 
the appeal letter mentions). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity Modulated Radiation Therapy (IMRT) (77014, G6015).  
 
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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services to gain independence 
and return home. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee has acute clinical and functional 
status change; thus, would require assessment by skilled nursing/therapy and skilled therapists recommend 
ongoing skilled therapy in a skilled nursing facility (patient CGA/min assist with mobility, beneath PLOF). The 
documentation shows that the enrollee requires daily skilled services on an inpatient basis in a SNF. 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 been met. The Plan must continue coverage for the SNF skilled service 
until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day 
Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility 
(SNF) care.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a retainer crowns (D6750) for teeth 8, 10, 13 and 14 and pontics 
(D6240) for teeth 9, 11, and 12. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford the cost of a bridge 
without insurance. The Plan denied your request. The Plan says that only one tooth is allowable on each side of 
the bridge. double abutments are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our physician 
reviewer found the documentation provided meets the criteria for coverage for a replacement bridge to replace 
missing teeth #'s 9, 11 and 12 with pontics (D6240) using teeth #'s 8, 10, 13 and 14 as abutment retainers 
(D6750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a retainer crowns (D6750) for teeth 8, 10, 13 and 14 and pontics (D6240) for teeth 9, 11, and 12.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that your mouth needs to be fixed 
because you cannot eat without your dentures. You say that the records you received don't work for you and 
this is why you need the reinstatement of your denture benefits. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. The Plan says that your dental 
provider has seen you for two adjustments, and that they are willing to assist with further issues you are having 
with your current dentures. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 10, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20610-LT, 20610-RT, J7324-LT, J7324-
RT, and 77002 billed for November 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 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 77002 is fluoroscopic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). 
 
We find that CPT code 77002 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met.  
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows procedure codes 20610-LT, 20610-RT, J7324-LT, 
and J7324-RT were billed with mismatched diagnosis codes. The diagnosis pointers on the claim append a 
right-sided diagnosis code for the -LT modifier and a left-sided diagnosis code for the -RT modifier. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 20610-LT, 20610-RT, J7324-LT, 
J7324-RT, and 77002 billed for November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99213) provided on December 10, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (99213) is included in the global 
surgery payment for the procedure (36475) provided on the same date of service. 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 the services (99213) provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx Melanoma gene expression profiling (GEP) 
(81599) provided on March 8, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage of this test are not met in this case. 
 
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 laboratory services. Our physician 
reviewer found despite commercially available GEP tests being marketed to risk stratify cutaneous melanomas, 
current GEP platforms do not provide clinically actionable prognostic information when combined or 
compared with known clinicopathologic factors (eg, sex, age, primary tumor location, thickness, ulceration, 
mitotic rate, lymphovascular invasion, microsatellites, and/or SLNB status) or multivariable nomograms/risk 
calculators. Furthermore, the clinical utility of these tests to inform treatment recommendations and predict 
patient outcomes has not been established. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for DecisionDx Melanoma gene expression profiling (GEP) (81599) provided on March 8, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. 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. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumbar spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found absent a red flag, a 
consultation to determine if prescribed medications are working and absent a 6-week trial of conservative 
management including physical therapy the medical necessity of the requested MRI of the lumbar spine has not 
yet been established. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service November 
17, 2022. 
 
You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This 
means that no TC billing is recognized because payment for the underlying clinical laboratory test is made to 
the hospital, generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT 
code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, we decided 
that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code(s) 85060 billed for date of service November 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 16, 2021, 
through December 22, 2021, and billed with diagnosis code N17.0. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis code N17.0 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of N17.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.0-acute kidney 
failure with tubular necrosis. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
secondary diagnosis of N17.0-acute kidney failure with tubular necrosis. Our physician reviewer found the 
member's initial creatinine level was at 1.59 and normalized to 0.92 with intravenous ceftriaxone hydration. 
Along with treatment of the member's conditions. There was no clinical or laboratory evidence of acute kidney 
failure with tubular necrosis. Therefore, diagnosis code N17.0-acute kidney failure with tubular necrosis is not 
the appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 16, 2021, through December 22, 2021, and billed with 
diagnosis code N17.0.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided on October 26, 2022. 
 
You asked the Plan to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies. You say 
that this claim should be covered. The Plan denied your request. The Plan says this device and supplies are not 
covered for chronic low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that this device is not covered for chronic low back 
pain. 
 
We looked at the file and Medicare rules. The medical records show that this device has been requested to treat 
chronic low back pain. Based on this information, we decided that Medicare rules for coverage of the 
Transcutaneous Electrical Nerve Stimulators (TENS) unit supplies have not been met. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) provided on 
October 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the chest, single view (71045) provided on 
September 28, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says diagnosis code Z11.1 has a code first note and is not 
acceptable as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that preprocedural chest X-rays in the absence of 
symptomatic pulmonary or cardiac disease(s), chest X-rays in the absence of signs or symptoms, and chest X-
rays for minor trauma of the head, lower back or extremities are not reasonable and necessary. 
 
This is being done as a screening without any signs/symptoms. Based on the records available, the chest- x-ray 
is considered screening and is not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray 
of the chest, single view (71045) provided on September 28, 2022.