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

We decided that the Plan does not have to pre-approve office visits, x-rays, and electrical heart tracing for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says no clinical information is provided as to why multiple visits and multiple x-rays/ECGs
would be needed.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the very limited records, there is no documented history of present illness, no documented
physical exam, and no documented objective laboratory data. In this circumstance the limited documentation
does not support the medical necessity for x-rays or electrocardiograms.
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 pre-approve office visits, x-rays, and electrical heart tracing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3-dimensional (3D) conformal image-guided radiation
therapy (IGRT).
You asked the Plan to pre-approve 3D conformal IGRT. You say that you are appealing with records. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because the requested
IGRT is not medically reasonable or 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 3D conformal IGRT. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found guidelines do not include IGRT among the recommendations for treatment of the
enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 3D conformal IGRT have not been met. Therefore, we decided that the Plan
does not have to pre-approve 3-dimensional (3D) conformal image-guided radiation therapy (IGRT).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does
not need daily skilled nursing or therapy services.
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 SNF services. Our physician reviewer
found that the enrollee is at contact guard assist using a rolling walker, moderate assist for bed mobility, and
minimal assist for transfers. This enrollee does not require skilled nursing services with the specialized skill,
knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically
necessary and reasonable treatment. He had no complex wound care or other skilled nursing need. His
functional level does not require ongoing professional skilled therapy only in a SNF. He does not require
skilled nursing or skilled therapy on a daily basis. As a practical matter this enrollee does not require the
necessary services on 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON CT imaging. You say that you have gotten imaging done at this provider in the past and do not feel comfortable going to a hospital facility due to the risk of COVID-19. The Plan denied your request. The Plan says it was found that your network has non-hospital imaging facilities able to provide this care.
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 CT scan of the chest to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 22,
2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the non-contracted payer has
inappropriately denied the claim as not medically necessary. The Plan denied your request. The Plan says this
enrollee did not meet inpatient criteria. Treatment could have safely been provided in observation.
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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found in the case of this enrollee, she did not appear to have ACS, but did have atrial
fibrillation which would have been appropriate enough to treat under observation status, especially considering
her hospice and DNR status. Other tests and monitoring could have been completed during observation care or
as outpatient. Therefore, the provided documentation suggested that the enrollee did not require more than a
two-midnight stay at the hospital.
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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided December 22, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve 12 months continuation of rental of a home ventilator, any type,
used with non-invasive interface.
You asked the Plan to pre-approve 12 months rental of a home ventilator (E0466). You say that the enrollee is
at risk for death without the ventilator. The Plan denied your request. The Plan says that the enrollee did not
meet criteria.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 12 months rental of a home ventilator
(E0466). Our reviewer says that criteria for continued coverage of a home ventilator are met. Our physician
reviewer found this enrollee has very severe restrictive lung disease, in part caused by paralysis of the right
diaphragm. This is causing chronic hypercarbic respiratory failure. The enrollee has been successfully managed
on a home ventilator since at least April of 2019. The most recent usage report meets minimum usage
requirements of at least 4 hrs/day for at least 70% of days. A home ventilator is considered reasonable and
necessary for this enrollee, and the denial is overturned.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 12 months rental of a home ventilator (E0466) have been met. Therefore, we
decided that the Plan has to pre-approve 12 months continuation of rental of a home ventilator, any type, used
with non-invasive interface.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the thorax.
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial
The Plan denied your request. The Plan says the documentation does not support that you meet criteria for the
requested CT scan.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We looked at the file and Medicare rules. Review of the file shows that medical records were not provided. The
plan requested medical records from your provider various times with no reply. Without medical records, there
is no proof that the requested CT is medically necessary. Based on this information, we decided that Medicare
rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to preapprove
a CT scan of the thorax.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sertraline.
You asked the Plan to pre-approve Sertraline. The Plan denied your request. The Plan says this drug is not
covered under your medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Sertraline.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) to include power
tilt/recline and power elevating leg rests.
You asked the Plan to pre-approve the power wheelchair and accessories. You say that while it is understood
that the enrollee received a power wheelchair 2 years ago, it is strongly recommended he be granted the use of
a power wheelchair with tilt in space technology. The Plan denied your request. The Plan says a pressure
reducing cushion and backrest can be added to the existing wheelchair. Medicare assumes a wheelchair will
have at least five years of useful life and this wheelchair is now two years old as it was purchased 03/07/2018.
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 power wheelchair and accessories.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found based on review of the available records, the enrollee does not meet
criteria for coverage for the requested group 3 power mobility chair even though this enrollee has a personal
mobility deficit of left hemiplegia that impairs participation in MRADLs. Additionally, his current chair is 2
years old and no documentation that anything was not functioning or in disrepair. He was discharged home
walking with cane and so his mobility deficit could be helped to an extent by the use of a cane and the Group 2
chair. He can safely operate a PMD. Based on review of available records, the enrollee does not meet criteria
for coverage for the requested the group 3 multi power wheelchair K0861 to include power tilt/recline and
power elevating leg rests does not meet medical necessity criteria under Medicare National Coverage
Determination (NCD) for Mobility Assistive Equipment (MAE).
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 power wheelchair and accessories have not been met. Therefore, we decided
that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) to include power tilt/recline
and power elevating leg rests.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from February 26, 2020, to
February 28, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was
stable for transfer prior to admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient care. Our reviewer says that the
requested inpatient care considered post-stabilization care. Our physician reviewer found that the enrollee is a
91-year-old who male who arrived at the ED unresponsive with a Glasgow coma score of 3 in triage. All
essential testing for a cause was negative for acute changes including CT brain and labs. Prior to admission to
the hospital, it was noted that he was responsive and had a Glasgow coma score of 15 with stable vitals except
for an elevated blood pressure (168/79). According to the provided ED notes, there was insufficient evidence of
the enrollee not being stable enough to transfer on February 26, 2020. He appeared stable and significantly
improved prior to admission. According to the notes, the enrollee appeared to be stable enough for transfer on
February 26, 2020, at 19:08.
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 inpatient care have not been met. Therefore, we decided that the Plan does
not have to pay for the inpatient care provided from February 26, 2020, to February 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you require coverage
for additional routine transportation trips to your dialysis appointments for the rest of the year. You say that
you have been on dialysis for the past three years and cannot miss your appointments. The Plan denied your
request. The Plan says the benefit for routine transportation trips has been exhausted.
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 Plan's coverage rules apply in this
case. The Plan covers a maximum of 48 one-way routine transportation 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 trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from
February 2, 2020 at 9:47am through February 3, 2020.
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post-stabilization care. Our physician
reviewer found the treating physicians did not document that the patient was not stable for transfer on any
date/time after 9:46 am February 2, 2020. Based on the clinical documentation, the patient appeared to be
stable for transfer via ambulance on and after 9:46 am on February 2, 2020.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan
does not have to pay for post-stabilization care provided to the enrollee from February 2, 2020 at 9:47am
through February 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is unable to be alone. The Plan
denied your request. The Plan says the enrollee does not have skilled nursing or therapy needs that need to be
provided on a daily basis.
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 SNF services. Our physician reviewer
found that the enrollee remains non-ambulatory. She is at maximum assist for bed mobility and transfers. A
therapy evaluation notes decreased left upper extremity strength for function, decreased endurance,
participation in home tasks and coordination, and functional mobility. The enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have
complex wound care or other ongoing SNF level SN need. Her functional level does not require skilled therapy
services only in a SNF. She does not require skilled nursing or skilled therapy services (or a combination of
these services) on a daily basis. As a practical matter, this enrollee does not require the necessary services on 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) (76390).
You asked the Plan to pre-approve magnetic resonance spectroscopy. You say that this is medically necessary.
The Plan denied your request. The Plan says this is a non-covered service.
The Plan must follow Medicare rules. Medicare rules say that all indications of magnetic resonance
spectroscopy are non-covered.
We looked at the file and Medicare rules. Magnetic resonance spectroscopy is not a covered service. Based on
this information, we decided that Medicare rules for coverage of magnetic resonance spectroscopy have not
been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance spectroscopy
(MRS) (76390).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF transfer and stay.
You asked the Plan to pre-approve the SNF transfer and stay. The Plan denied your request. The Plan says the
enrollee does not need more skilled therapy care, more complicated medical care, complicated wound care, or
antibiotics administered through the veins that cannot be done by a nurse at home.
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 transfer and stay. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Although the enrollee has skilled therapy
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for
coverage of the SNF transfer and stay have not been met. Therefore, we decided that the Plan does not have to
pre-approve a SNF transfer and stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aspiration and/or injection or large joint/capsule.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no documentation of conservative measures or completion of an orthopedic
evaluation.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there has been no trial of conservative therapy or an orthopedic consultation before
interventional therapy. Therefore, this request is deemed 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve aspiration and/or injection or large joint/capsule.