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

 
We decided that the Plan does not have to pre-approve transthoracic echocardiogram (93307). 
 
You asked the Plan to pre-approve transthoracic echocardiogram. You say that the medical records should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not 
support the medical necessity of the requested service. 
 
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 transthoracic echocardiogram. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the records the enrollee has no cardiac symptoms, no cardiac 
physical exam abnormalities and a near normal ECG that is not concerning for any acute cardiac condition. In 
this circumstance the documentation does not support the medical necessity for an echocardiogram.  Coverage 
criteria are not met since there are no documented covered indications for the procedure. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transthoracic echocardiogram have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transthoracic echocardiogram (93307).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of multiple sclerosis, asthma, gastroesophageal reflux disease, anxiety and depression who 
presented to the acute hospital on 10/29/2020 with abdominal pain, weakness and constipation. She was treated 
in the hospital with laxatives, intravenous fluids, hemorrhoidal cream and Calmoseptine ointment. She has 
refused medications and blood draws in the hospital. She has been non-ambulatory since July 2020 and is 
reported to be essentially wheelchair bound. She is weak and deconditioned and is working with physical and 
occupational therapy. She is not able to stand or walk and is maximum assist for transfers and moderate to 
maximum assist for most activities of daily living. She is reported to be medically stable for discharge. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
 
 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trial of electrical treatment, spinal cord stimulator coded 
as 63650, 63655 and 63685. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that your spinal cord stimulator surgery 
denied because it was not documented in the medical history and you would like to appeal. The Plan denied 
your request. The Plan says the records provided do not support that the requested procedure is medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve spinal cord stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is diagnosed with chronic low back pain not improved with conservative 
treatments. Epidural injections were noted to have been used in the past with no lasting improvement. A 
request for a spinal cord stimulator was made. The records state that the enrollee declined any surgical options 
presented to her. Surgical options were not noted to be unsuitable or contraindicated for this enrollee, however. 
Therefore, according to the records provided this patient does not effectively meet the criteria for a spinal cord 
stimulator at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve trial of electrical treatment, spinal cord stimulator coded as 63650, 63655 and 
63685.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that no prior authorization is required for an 
observation stay. The Plan denied your request. The Plan says the documentation does not support the medical 
necessity required to approve the request. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 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 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET scan with CT, skull base to mid-thigh for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. 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. Medicare rules say that PET scans 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee had 
metastatic renal cell carcinoma resected in 2003 and has remained without evidence of disease. She has no new 
reported symptoms or signs of recurrence. PET scans are not indicated for the surveillance of renal cell 
carcinoma. The service is not reasonable or 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 the scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET scan with CT, skull base to mid-thigh for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met. 
 
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. In this case, ongoing care needs include oxygen supplementation, intravenous antibiotics, 
surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in 
this case requires services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no required medical services identified that are available at the LTACH, that are not 
available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rexulti 0.5 mg tablet. 
 
You asked the Plan to pre-approve Rexulti. You say that Rexulti is medically necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says this medication falls under Part D coverage, but the 
member has no Part D pharmacy benefit. 
 
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 Rexulti 0.5 mg tablet.  
 
Benefits for Rexulti 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor 2 and Factor V Leiden (F2/FVL) genetic testing. 
 
You asked the Plan to pre-approve the F2/FVL testing. You say that this testing is necessary to determine 
whether the enrollee has a genetic clotting disorder. The Plan denied your request. The Plan says the enrollee 
does not have deep vein thrombosis, so this is not covered. 
 
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 F2/FVL testing. Our reviewer says 
that the requested testing is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the laboratory testing was not done for evaluation of a venous 
thromboembolism. Therefore, the criteria for coverage as specified in the LCD were not met. Nor, would the 
completed testing otherwise have been reasonable and necessary. The enrollee is known to have a history of 
atherosclerotic disease. Her history was notable for coronary artery disease, requiring quadruple bypass, 
diabetes, high lipids, obesity, hypertension and tobacco use. The history of significant atherosclerotic disease is 
the most likely etiology of the enrollee's strokes. Furthermore, the current guidelines from the American Stroke 
Association also do not readily support provision of such testing, where it is noted that "the usefulness of 
screening for thrombophilic states in patients with ischemic stroke or TIA is unknown."  
 
Given that a hypercoagulable etiology is not the most likely etiology of the member's strokes, and that the 
management of her condition going forward would not readily be altered based on the results of such testing 
(as she was already on aspirin and Plavix secondary to coronary artery disease), this testing would not be 
reasonable and 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 F2/FVL testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Factor 2 and Factor V Leiden (F2/FVL) genetic testing.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a CardioMEMs system. 
 
You asked the Plan to pre-approve a CardioMEMs system. 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 health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide plan documentation or medical records. 
Without this documentation, the Plan denial is not substantiated and we must find in your favor. Therefore, we 
decided that the Plan has to pre-approve a CardioMEMs system.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (CPT 97112) provided to the 
enrollee on May 18, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the GP modifier is required for physical therapy. 
 
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 97112 is "Therapeutic procedure, one or more areas, each 
15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the claim 
submitted did not have required modifier of GP (Physical Therapy), GO (Occupational Therapy, or GN for 
(Speech-Language pathology. 
 
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 physical therapy services (CPT 97112) provided to the enrollee on May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zilretta injection (J3304) for repeated use. 
 
You asked the Plan to pay for a Zilretta injection. You say that surgery is not an option for you and that the 
only relief for your knee pain is Zilretta. The Plan denied your request. The Plan says rules for coverage for 
Zilretta have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 pay for a Zilretta injection. Our reviewer says that 
the requested product is not medically accepted as prescribed. Our physician reviewer found that repeated use 
of Zilretta is not FDA-approved, supported by the Medicare-approved drug compendia, or the drug 
manufacturer. Repeat administration of Zilretta is reported to be not indicated and it is not intended for repeat 
administration. 
 
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 Zilretta injection have not been met. Therefore, we decided that the Plan does 
not have to pay for a Zilretta injection (J3304) for repeated use.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy encourages you to try the equally effective drug - Retacrit. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of Retracrit before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug. There is no documentation provided indicating that the plan's required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SI (sacroiliac) joint injections. 
 
You asked the Plan to pre-approve SI joint injections. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve SI joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of chronic pain, neck pain, cervical radiculopathy, bilateral 
shoulder pain, low back pain with lumbar radiculopathy, multiple joint pain, and chronic SI joint pain. The pain 
is reported to interfere with functional activities. Medications include Oxycodone IR and Oxycontin. Faber 
Test was positive. There should be documentation of at least 3 positive exam findings to suggest the diagnosis. 
This is especially true in this case with so many overlapping lumbar area diagnoses. The five tests most 
recommended include the pelvic distraction test, pelvic compression test, thigh thrust test, FABER (Patrick's 
test) and Gaenslen's test. There was insufficient evidence of positive findings for sacroiliac joint arthropathy in 
the records reviewed. Therefore, the enrollee does not meet criteria for the requested 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 SI joint injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SI (sacroiliac) joint injections.