Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound therapy (97035), manual therapy (97140), 
and therapeutic exercises (97110). 
 
You asked the Plan to pre-approve ultrasound therapy, manual therapy, and therapeutic exercises. 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 does not cover chiropractic maintenance 
care.  
 
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 ultrasound therapy, manual therapy, 
and therapeutic exercises. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found submitted chart notes reveal treatment from January 29, 2020 through July 27, 2020 revealing 
ongoing ache and pain complaints, functional limitations, along with the same or similar findings and treatment 
rendered, revealing little evidence of improvement and no evidence of a reasonable expectation of recovery or 
improvement of function. As chart notes reveal the same or similar complaints and subjective numerical values, 
range of motion findings, restricted joint motions, orthopedic findings, exercises and posture notations, with 
treatment rendered over a number of months, the treatment is considered maintenance therapy as clinical 
improvement has not occurred or will likely occur with further treatments. Treatments are medically 
unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound therapy, manual therapy, and therapeutic exercises have not been 
met. Therefore, we decided that the Plan does not have to pre-approve ultrasound therapy (97035), manual 
therapy (97140), and therapeutic exercises (97110).
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 you need physical therapy to build up strength. The 
Plan denied your request. The Plan says you do not require an intensive, multi-disciplinary team approach to 
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 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 physician reviewer found 
that you are not medically able to withstand IRF therapies. There is no evidence of complex medical issues that 
require monitoring by an inpatient rehab physician three times per week, or a need for acute rehab nursing care. 
While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an 
intensive therapy program with therapy 3 hours per day when she has poor activity tolerance with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. Therefore, an admission to an IRF 
is not medically necessary based on lack of medical complexity and inability to tolerate IRF level of therapies. 
 
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: 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. The Plan denied your request. The Plan says there is no indication 
that the enrollee could tolerate 15 hour of therapy a week, or needs a rehab physician visit three times a week. 
 
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 physician reviewer found 
that you are generally medically stable with an old hemorrhagic stroke, with dense deficits, and with no recent 
neurological or Orthopedic events. There is no evidence of complex medical issues that require monitoring by 
an inpatient rehab physician three times per week, or a need for acute rehab nursing care. Currently, you are 
still very dependent and cognitively impaired.  While you may benefit from continuing physical, occupational, 
and speech therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day 
with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Therefore, an a 
admission to an IRF is not medically necessary based on the lack of medical complexity, and inability to 
tolerate IRF level of therapies with fatigue and dependent functional status. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal treatment - four or more teeth per quadrant 
on teeth #9-16 (upper left) and #1-8 (upper right) (D4341). 
 
You asked the Plan to pre-approve periodontal treatment - four or more teeth per quadrant on teeth #9-16 
(upper left) and #1-8 (upper right). 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. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers periodontal 
treatment - four or more teeth per quadrant for 2 quadrants once every 24 months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of periodontal treatment - four or more teeth per quadrant on teeth #9-16 (upper left) and #1-8 (upper 
right) have not been met. Specifically, two quadrants were already approved for periodontal treatment within 
the past 24 months. Therefore, we decided that the Plan does not have to pre-approve periodontal treatment - 
four or more teeth per quadrant on teeth #9-16 (upper left) and #1-8 (upper right) (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and office visits to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and office visits to be provided by an OON provider. You say 
that this facility is able to offer you the best cancer treatment and you do not want to go anywhere else. The 
Plan denied your request. The Plan says there are in-network providers that are able to provide these services. 
Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation and office visits to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiogram for the enrollee. 
 
You asked the Plan to pre-approve the echocardiogram. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical record is interpreted to indicate that the review of systems and 
the rest of the physical examination are non-contributory. 
 
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 echocardiogram. Our reviewer says 
that the requested echocardiogram is not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance of isolated edema without other symptoms or findings of 
congestive heart failure, the documentation does not support the medical necessity for an echocardiogram. 
Coverage criteria are not met since there is no documented covered indication for the procedure.  Specifically, 
"Echocardiography is not recommended in patients with edema when the jugular venous pressure does not 
appear to be elevated." 
 
 
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 echocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an echocardiogram for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a functional electrical stimulator. 
 
You asked the Plan to pre-approve functional electrical stimulation. You say that you have determined that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization 
for this device is correct, because this device is not covered for the enrollee's condition. 
 
The Plan follows Medicare rules. The rules say that functional electrical stimulation is covered for enrollees 
that meet all of the above clinical criteria. 
 
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 functional electrical stimulation. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested functional electrical 
stimulation. Our physician reviewer found it is not clear from the limited records provided that the enrollee can 
demonstrate balance and control to maintain and upright support posture independently. The physical therapy 
notes indicated that the enrollee has poor dynamic and static balance. In this setting it cannot be independently 
determined that the enrollee has the pre-requisite stability for the use of this device. Furthermore, there was not 
a formal indication regarding the enrollee's ability to demonstrate independent standing tolerance for at least 3 
minutes.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of functional electrical stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve use of a functional electrical stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx 300mg dose-2 syringe. 
 
You asked the Plan to pre-approve the syringe. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Cosentyx 300mg dose-2 
syringe.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of benrolizumab (Fasenra). 
 
You asked the Plan to pre-approve Fasenra. You say that despite multiple previous treatments, the enrollee 
continues to struggle with her severe persistent asthma. The Plan denied your request. The Plan says the denial 
of authorization for this drug is correct, because the enrollee does not have asthma with eosinophilic 
phenotype. 
 
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 Fasenra. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Fasenra. Our physician reviewer found 
benralizumab is approved by the Food & Drug Administration (FDA) for the treatment of severe asthma in 
patients with eosinophilic phenotype. The documentation does not support that the enrollee has a diagnosis of 
eosinophilic asthma. The documentation does not support that the requested benralizumab is safe and effective 
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 Fasenra have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of benrolizumab (Fasenra).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the requested item is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Freestyle Libre CGM. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the criteria requires 3 or more shots 
of insulin per day and 4 blood glucose level checks per day to qualify for a CGM Libre. You are not taking 
insulin nor checking blood glucose levels as far as what can be found in the records. We are also not told why a 
glucometer is not something that suffices for your blood glucose monitoring needs. Hence you do not meet the 
criteria for a CGM. 
 
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 Freestyle Libre CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01936) provided on February 17, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has no significant PMH to warrant MAC. There is no documentation in the enrollee's 
record indicating that it is medically necessary to have an anesthesiologist present during a lumbar ESI. In 
addition, the anesthesiologist documented that the enrollee did not receive preoperative, intraoperative, or 
postoperative fluids and no documentation of any medications administered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services (01936) provided on February 17, 2020.
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 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 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are generally medically stable and the documentation does not support that you 
have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical, 
medicine, and rehabilitation (PMR) physician three times per week. While you are reasonably expected to 
benefit from continuing physical therapy (PT) and occupational therapy (OT), the documentation does not 
support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 10, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that an "order" is a communication from the treating 
physician/practitioner requesting that a diagnostic test be performed for a beneficiary. While a physician order 
is not required to be signed, the physician must clearly document, in the medical record, his or her intent that 
the test be performed. 
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided on June 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided January 21, 2020 to January 
27, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient criteria are met in this case. 
The Plan denied your request. The Plan says that the inpatient services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the evaluation revealed an exacerbation of chronic obstructive pulmonary disease and chronic 
hypercapnic respiratory failure. He was treated with nebulizer treatments and IV antibiotics. He was admitted. 
His condition stabilized and improved with medical treatment and he was discharged home on January 27, 
2020 when considered medically stable. The review has determined that the record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided January 21, 2020 to January 27, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0260) provided on December 13, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 G0260 is "Injection procedure for sacroiliac joint; 
provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography". 
 
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 use 
of code G0260 is not supported by the records provided. Our coding reviewer found that the medical records 
provided do not include documentation of an "injection procedure for sacroiliac joint; provision of anesthetic, 
steroid and/or other therapeutic agent, with or without arthrography" being performed twice on the left side on 
December 13, 2018. 
 
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 (G0260) provided on December 13, 2018.