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

 
We decided that the Plan has to pre-approve Keytruda, Zirabev, Dexamethasone, Famotidine, 
Diphenhydramine, Carboplatin, and Paclitaxel. 
 
You asked the Plan to pre-approve Keytruda, Zirabev, Dexamethasone, Famotidine, Diphenhydramine, 
Carboplatin, and Paclitaxel. You say that the services are necessary. The Plan denied your request. The Plan 
says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda, Zirabev, Dexamethasone, 
Famotidine, Diphenhydramine, Carboplatin, and Paclitaxel. Our reviewer says that the services are medically 
necessary. Our physician reviewer found Pembrolizumab is FDA approved for the treatment of persistent, 
recurrent, or metastatic cervical cancer (in combination with chemotherapy, with or without bevacizumab) in 
patients whose tumors express PD-L1 (CPS =1), as determined by an approved test. This enrollee meets these 
criteria. The service is reasonable and 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 Keytruda, Zirabev, Dexamethasone, Famotidine, Diphenhydramine, 
Carboplatin, and Paclitaxel have been met. Therefore, we decided that the Plan has to pre-approve Keytruda, 
Zirabev, Dexamethasone, Famotidine, Diphenhydramine, Carboplatin, and Paclitaxel.  
 
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 pay for an additional computed tomographic angiography (CTA) of 
the chest (71275) provided on January 23, 2022. 
 
You asked the Plan to pay for an additional CTA of the chest. The Plan denied your request. The Plan says the 
records confirm that only one CT scan of the thorax was performed. The Plan also says the records submitted 
do not indicate that two separate services were performed. 
 
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 71275 is computed tomographic angiography, chest 
(noncoronary), with contrast material(s), including noncontrast images, if performed, and image 
postprocessing. 
 
 
 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 an additional CTA of the chest. Our reviewer says that the 
additional CTA is not supported in the medical records. Our reviewer found only a single CTA of the chest was 
done on January 23, 2022. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional CTA of the chest have not been met. Therefore, we decided that 
the Plan does not have to pay for an additional computed tomographic angiography (CTA) of the chest (71275) 
provided on January 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis provided on April 4, 2022. 
 
You asked the Plan to pay for extracorporeal photopheresis. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage. 
 The Plan must follow Medicare rules. Medicare rules say that extracorporeal photopheresis is only covered for 
bronchiolitis obliterans after a transplant and within a clinical trial. 
 
We looked at the file, and Medicare rules. We find that there is no evidence in the file that the enrollees 
condition is related to a transplant. Based on this information, we decided that Medicare rules for coverage of 
extracorporeal photopheresis have not been met. Therefore, we decided that the Plan does not have to pay for 
extracorporeal photopheresis provided on April 4, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has 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 that the enrollee's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and  
 occupational therapy, the documentation does not reveal that the enrollee requires these therapies on an 
intensive IRF level. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on December 21, 
2021. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that the DecisionDx-SCC testing provided 
on December 21, 2021, was medically necessary. The Plan denied your request. The Plan says the DecisionDx-
SCC testing provided on December 21, 2021, was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the DecisionDx-SCC testing. Our reviewer 
says that the DecisionDx-SCC testing provided on December 21, 2021, was not medically necessary. Our 
physician reviewer found based on the medical records provided there is no documentation that the 
DecisionDx-SCC testing provided on December 21, 2021, at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee per Social Security Act, Section 1862 (a)1(A) and the 42 
CFR Section 411.15(k). Provided medical records do not document how the results of the test would be used in 
the management of this enrollee at the time of the testing. 
 
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 DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SCC testing provided on December 21, 2021.
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 IRF is required for the enrollee as their current needs 
cannot safely be met a lower level of care. The Plan denied your request. The Plan says IRF is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as skilled nursing facility (SNF), 
home health or outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy and mastopexy. 
 
You asked the Plan to pre-approve a panniculectomy and mastopexy. You say that the requested 
panniculectomy and mastopexy is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested panniculectomy and mastopexy. 
 
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 panniculectomy and mastopexy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has had significant weight loss. The 
provided record is insufficient to determine whether the elements of the coverage criteria are satisfied. The 
record does not indicate that the enrollee's weight is stable or the presence of intertrigo not documented to be 
refractory to medical treatment. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 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 a panniculectomy and mastopexy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a panniculectomy and mastopexy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service November 3, 
2021. 
 
You asked the Plan to pay for procedure code 97110. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526.  
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 97110 
is a column II code to column I code 92526. 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 procedure code 97110 billed for date of service November 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213), periodontal scaling 
and root planing-four or more teeth per quadrant, for the upper arch (D4341), post and core (D2952), and a 
tooth colored crown for tooth number 10 (D2750).  
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested items/services. 
 
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 these 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 these items/services. Our reviewer says 
that the requested items/services are not medically necessary.  Our physician reviewer found that a review of the documentation indicates that the remaining abutment teeth 
are not suitable to support and retain an upper partial denture due to poor bone support. The upper arch 
contains two teeth per quadrant which does not meet the criteria for periodontal scaling and root planing which 
requires four or more teeth per quadrant. Tooth number 10 appears to have periapical pathology and poor bone 
support which does not meet the criteria for coverage of a post/core and a crown restoration. 
 
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 these items/services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an upper partial denture (D5213), periodontal scaling and root planing-four or 
more teeth per quadrant, for the upper arch (D4341), post and core (D2952), and a tooth colored crown for 
tooth number 10 (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that the enrollee has been 
insulin dependent diabetic for 40 years. She has frequent fluctuating blood sugars due to her poor appetite and 
not eating full meals. The fact that she is on fixed insulin shouldn't matter, the benefit of having a "CGM" 
includes an alarm that can be set for urgent low glucose. In addition to diabetes, the enrollee has refractory 
anemia, she gets weekly injections, her H/H has been low making finger pricks more difficult to obtain blood 
sample. This CGM provides painless scans rather than finger sticks. The Plan denied your request. The Plan 
says the enrollee does not meet coverage criteria for the requested CGM and supplies. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81406, 81162, 81408, 81201) provided on 
November 15, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. If there is no 
HCPCS/CPT code that describes the procedure, the laboratory shall report a miscellaneous or unlisted 
procedure code with a single unit of service. 
 
We looked at the file and Medicare rules. Multiple codes were billed for a single lab panel. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81406, 81162, 81408, 81201) provided on 
November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81270, 81338, 81279, 81219, G0452) provided 
on March 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the performance of multiple molecular tests 
regardless of whether the requisition lists the tests as a panel or individually, and completed on a single sample 
is considered to be a panel of tests and should be billed under a single CPT code. 
 
We looked at the file and Medicare rules. A single panel was billed using multiple codes. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81270, 81338, 81279, 81219, G0452) provided on 
March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 21, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 the lab services provided on September 21, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy. 
 
You asked the Plan to pre-approve stereotactic body radiation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
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 stereotactic body radiation therapy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found stereotactic body radiation therapy is indicated for enrollees with oligometastatic 
disease and is an established approach for the treatment of discrete lesions from cancer. You have 2 sites of 
oligometastases to be treated and the treatment itself is within accordance of accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stereotactic body radiation therapy have been met. Therefore, we decided that 
the Plan has to pre-approve stereotactic body radiation therapy.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device elbow wrist hand finger single or double upright includes microprocessor sensors all components and 
accessories custom fabricated (L8702). 
 
You asked the Plan to pre-approve the Myopro device. You say that the enrollee took the time to obtain an 
occupational therapy consultation and then got you all the required paperwork. The Myo-pro device is neither 
experimental not investigational. The Plan denied your request. The Plan says the requested device does not 
meet the requirements for approval. 
 
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 Myopro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional 
standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 Myopro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered upper extremity range of motion assist device elbow wrist hand finger 
single or double upright includes microprocessor sensors all components and accessories custom fabricated 
(L8702).