Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition.  The 
enrollees care needs, custodial and intermittent, can, as a practical matter, 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation 
in the Inpatient Rehabilitation Facility. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the enrollee is now at a level where she can transition from 
daily skilled services to services that are provided intermittently. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee no longer qualified for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs can, as a practical matter, 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage of the requested drug 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 not medically reasonable and necessary. Our physician reviewer found the enrollee is a 58-
year-old female with left breast cancer. In this case, the requested drug is not FDA-approved for the enrollee's 
condition. In addition, the use of Keytruda is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal as the enrollee's tumor is PDL1 negative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation (A0120). 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation trips for dialysis treatment twice a week. The Plan denied your request. The Plan says additional 
trips would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says treatment with Keytruda as first-line therapy for the 
enrollee's diagnosis does not meet coverage criteria. 
 
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 Keytruda is not medically reasonable and necessary. Our physician reviewer found the enrollee 
is an 81-year-old male diagnosed with hepatocellular carcinoma with Child-Pugh C. In this case, Keytruda is 
not FDA-approved for the enrollee's medical condition. In addition, the use of Keytruda is not supported by one 
of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal when 
involving decompensated cirrhosis (Child Pugh Class C). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail pathogen testing by polymerase chain reaction (PCR) 
provided on August 11, 2021. 
 
You asked the Plan to pay for the pathogenic PCR testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says there is insufficient evidence of the clinical utility of this testing. 
 
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 pathogenic PCR testing. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a review of the medical literature and clinical practice guidelines do not support PCR testing as a first line approach for evaluation of nail disorders and it is not widely accepted as standard of care. 
There is a lack of data to suggest these panels alter medical decision making. The review has determined that 
the items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the pathogenic PCR testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the nail pathogen testing by polymerase chain reaction (PCR) provided on August 
11, 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 this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program 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 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 has a past medical history of paraplegia and hypertension. She has ongoing weakness, and saw an 
outpatient provider for elevated blood pressure. There was no indication of a need for inpatient care for 
elevated blood pressure. Other 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, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that this enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that total electric beds will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95885, 95908, 95955) provided on March 3, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 services. Our reviewer says that the use of codes 95885, 
95908, and 95955 is not supported by the records provided. Our reviewer found that for code 95885, this 
procedure is performed with nerve conduction studies, per CPT code description. In this case, nerve conduction 
studies cannot be verified, and therefore this procedure would not be covered. For code 95908, the technical 
report describes pedicle screw stimulation, and therefore would not be reported with a nerve conduction studies 
procedure code. Nerve conduction studies measure amplitude and latency/velocity which is not documented in the report. For code 95955, the technical report does not include documentation of a "special EEG test". 
Documentation supports real time monitoring, therefore this procedure would not be reported as a baseline 
procedure code. All additional EEG testing would be inclusive to the primary intraoperative monitoring code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (95885, 95908, 95955) provided on March 3, 2021.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and your lungs were clear. You were at a supervision to contact guard to minimal assist level for 
functional mobility including gait to 170 feet with a rolling walker. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen (14) additional OT visits. 
 
You asked the Plan to pre-approve fourteen (14) additional OT visits. You say that additional OT is medically 
necessary. The Plan denied your request. The Plan says additional OT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 fourteen (14) additional OT visits.  Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated 
with outpatient therapies and should be independent with a home exercise program. There is no documentation 
of a recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fourteen (14) additional OT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve fourteen (14) additional OT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic agent injections (64483 and 64484) provided 
on September 8, 2021. 
 
You asked the Plan to pay for the anesthetic agent injections (64483 and 64484). You say that no authorization 
is required for 64483 and 64484. The Plan denied your request. The Plan says CPT code 64483 has an MUE 
value of 1, but 2 units were billed. The Plan also says that primary code 64483 is not eligible for payment, so 
CPT code 64484 is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. Medicare rules say that an add-on code is 
eligible for payment only if it is reported with an appropriate primary procedure performed by the same 
practitioner. 
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. We have confirmed that code 64484 is an add-on code to CPT code 64483. Since 
the primary code cannot be paid, the add on code cannot be paid. Based on this information, we decided that 
Medicare rules for coverage of the anesthetic agent injections (64483 and 64484) have not been met. Therefore, 
we decided that the Plan does not have to pay for the anesthetic agent injections (64483 and 64484) provided 
on September 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional PT visits. 
 
You asked the Plan to pre-approve six (6) additional PT visits. You say that the physical therapy that you were 
receiving was helping your condition and you are not confident enough to do the exercises on a standalone 
basis without the physical therapists help and guidance. You say that although you have felt improvement, you 
believe that at least 6 more months of PT is sufficient for a full recovery. The Plan denied your request. The 
Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 six (6) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient 
therapies and should be independent with a home exercise program. There is no documentation of a recent 
injury or decline in function. The additional therapy services are not an appropriate duration and frequency for 
treatment of your medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six (6) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six (6) additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (14001) provided on October 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 14001 is "Adjacent tissue transfer or rearrangement, 
trunk; defect 10.1 sq cm to 30.0 sq cm". 
 
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 services. Our reviewer says that the use of code 14001 is 
not supported by the records provided. Our reviewer found that the operative report describes a complex repair with undermining to create subcutaneous flap. An adjacent tissue transfer or rearrangement was not found in 
the documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (14001) provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81551) provided August 30, 2021. 
 
You asked the Plan to pre-approve the genetic testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered in males with previous 
negative prostate biopsy who are being considered for repeat biopsy. 
 
We looked at the file and Medicare rules. There is no record of a previous negative biopsy. 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 pre-approve genetic testing (81551) provided August 30, 2021.