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

 
We decided that the Plan does not have to pre-approve MRI of the abdomen. 
 
You asked the Plan to pre-approve an MRI of the abdomen. The Plan denied your request. The Plan says the 
MRI does not meet the Medicare NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the abdomen. Our reviewer 
says that an MRI of the abdomen is not medically necessary. Our physician reviewer found the documentation 
does not support less comprehensive diagnostic testing for the abnormal weight loss, to include additional 
blood work, scope, swallow test. The laboratory report consists of Herpes Simplex, STD testing, Lipid Panel, 
Renal Function Panel, as well as a most recent virtual visit for date of service January 21, 2022 documenting 
"Improving, seeing husband again, gaining weight; history of present illness (HPI) talking to husband and 
starting counseling. Separated for 2 months.  Getting new partials. Gaining weight and eating better.  Sleeping 
better with trazodone. Colonsocopy is coming up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the abdomen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the abdomen.
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 you need urgent rehab after surgery. The Plan denied 
your request. The Plan says your ongoing needs can be met at a lower level of care. 
 
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 physician reviewer found 
that you were admitted to the acute hospital after sustaining a fall, sustaining a hip fracture. You are currently 
at a minimal assist level for mobility and activities of daily living. You are medically stable and do not need 
close physician supervision 3 times a week.  At your current functional level, you do not need intensive therapies consisting of at least 3 hours of therapy 
per day. Therefore, an admission is not medically necessary based on medical stability and lack of medical 
complexity, and lack of rehab nursing needs. 
 
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 the continuous glucose monitor (CGM) supplies 
(K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you are not insulin treated with multiple daily injections. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) supplies (K0553).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health PT services. 
 
You asked the Plan to pre-approve home health PT services. The Plan denied your request. The Plan says home 
health PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy.  A doctor must certify the need for home health care services. 
 
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 home health PT services. Our reviewer 
says that home health PT is not medically necessary. Our physician reviewer found based on the documentation 
provided, the health Plans denial should be upheld. The enrollee is noted not to be homebound. The enrollee 
can walk 100 feet with supervision. As such, home health PT services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health PT service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health PT services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no red flags noted, and there has been no conservative management for the 
radicular symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no weakness or 
reflex abnormality. There is no plain x-ray report in the records. There has been no electromyography. There 
are no red flags given to mandate an immediate MRI without a six week trial of conservative management. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760). 
 You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator will be denied 
as not medically necessary if any of the criteria in the Medicare Rules section are not 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 an ultrasonic osteogenesis stimulator. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no specific 
clinical rationale foe the requested bone stimulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on December 13, 2021. 
 
You asked the Plan to pay for anesthesia 01232. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this code is correct, because the records do 
not include an anesthesia report. 
 
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 01232 is anesthesia for open procedures involving upper 
two-thirds of femur; amputation. 
 
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 anesthesia 01232. Our reviewer says that this code does not 
meet the criteria for payment. Our reviewer found an anesthesia report was not included in the submitted 
documentation, so this code cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia 01232 have not been met. Therefore, we decided that the Plan does 
not have to pay for anesthesia provided on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from October 3, 2020, to 
October 30, 2020, as billed with Diagnosis Related Group (DRG) 853. 
 
You asked the Plan to pay for inpatient care billed with DRG 853. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 853 is not supported as the principal diagnosis of sepsis, unspecified organism (A41.9) is 
not supported in the medical record. The Plan argues that DRG 659 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 853. Our 
reviewer says that the principal diagnosis of sepsis, unspecified organism (A41.9) is not supported in the 
medical record. Our physician reviewer found that based on the objective testing and physical findings, the 
enrollee did not exhibit signs or symptoms of organ failure directly related to an exaggerated response to the 
infection, and the symptoms and abnormal test values were related to dehydration, seizure, and chronic 
conditions. Therefore, the diagnosis of sepsis is not supported in the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 853 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from October 3, 2020, to October 30, 
2020, as billed with Diagnosis Related Group (DRG) 853.
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 enrollee is not getting much therapy at the SNF. 
The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary 
approach to daily 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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for surgical management of humerus and patellar 
fractures after a fall. Medical problems are stable. The enrollee does not require treatment by multiple therapies 
in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine and administration provided on 
December 9, 2021. 
 
You asked the Plan to pay for the tetanus vaccine and administration. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this vaccine is not 
among those covered under the Part D benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine and 
administration provided on December 9, 2021.  
 
Benefits for the tetanus vaccine and administration 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic and 
lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no records showing a recent course of treatment, such as physical therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found the clinical workup 
of this morbidly obese diabetic patient is not complete enough to mandate MRI of the thoracic and lumbar 
spine based upon the info provided. The duration of the pain has not been stated. There is no detailed physical 
exam, although no dermatome findings are seen. The enrollee is diabetic, and is at risk for discitis, especially 
after the recent dental extraction for which she was hospitalized and given antibiotics. The problem is that no 
plain films of the spine are in the records, and there is no laboratory work such as white count, c-reactive 
protein (CRP) and erythrocyte sedimentation rate (ESR) for evaluation. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the thoracic and lumbar spine for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 18, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says screening asymptomatic patients for 
cardiovascular risk is statutorily excluded by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The enrollee is not noted to have a personal history of heart disease. They have risk factors but no 
signs/symptoms of illness. As such, this is considered a screening test and is not among those covered by 
Medicare. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred providers.  
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Freestyle Lite test strips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health services. You say that you are currently transitioning to a new 
primary care provider (PCP). You also say that the new PCP does not have your correct or current medical 
records. The Plan denied your request. The Plan says the necessary documentation was not provided. The Plan 
also says in order to receive home health services, such as a home health aide, you must first get approval from 
your PCP. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan requires care to be coordinated through your primary care physician (PCP). The file does not indicate that your PCP has referred you for these services. Therefore, we decided that the Plan does not have to pre-
approve home health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you have no teeth, are on a fixed 
income, and cannot afford the dentures. The Plan denied your request. The Plan says these services are not 
covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub. 
 
You asked the Plan to pre-approve a walk-in tub. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not primarily used for a medical purpose and is useful to a person in the 
absence of illness or injury. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate cancer genetic testing services (0005U). 
 
You asked the Plan to pre-approve prostate cancer genetic testing services. You say that this testing is 
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria have not been 
satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that prostate cancer genetic testing services will be 
covered when Prostate-Specific Antigen (PSA) testing results are less than 10 ng/mL. Your PSA is consistently 
above 10 ng/mL. Based on this information, we decided that Medicare rules for coverage of prostate cancer 
genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
prostate cancer genetic testing services (0005U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor. 
 
You asked the Plan to pre-approve a Dexcom continuous glucose monitor. You say that this would allow you 
to check your blood sugar more. The Plan denied your request. The Plan says the requirements for coverage 
have not been met. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom continuous glucose monitor.