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

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spinal canal 
and contents (72146). 
 
You asked the Plan to pre-approve an MRI. You say that this imaging is medically necessary. The Plan denied 
your request. The Plan says the criteria for an MRI are not met in this case. The records show that the enrollee 
has had surgery to treat the spine. The records provided do not include x-ray results taken after symptoms 
started which would show the need for further imaging. 
 
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. Our reviewer says that 
Medicare criteria for medical necessity are not met in this case. Our physician reviewer found the record does 
not include documentation of a post-surgery x-ray or any post-op physical therapy. There are no red flags 
which would necessitate an MRI 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the spinal canal and contents (72146).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair and accessories coded as K0823, 
E0973 and E2365 to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the enrollee was 
approved for a power wheelchair and it was received on 03/02/2022. Since then she has changed insurance and 
you are requesting authorization for the remaining 11 months of the rental cycle. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 the power wheelchair and accessories coded as K0823, E0973 and E2365 to be provided by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 infusions of ferric derisomaltose-iron. 
 
You asked the Plan to pre-approve 12 infusions of ferric derisomaltose-iron. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested amount of infusions 
are not medically necessary. 
 
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 12 infusions of ferric derisomaltose-
iron. Our reviewer says that the documentation does not support that the requested amount of infusions are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of iron 
deficiency anemia. The provided records document a hemoglobin level of 11.3 grams/dL with a ferritin of 183 
nanograms/mL; provided records do not document why six ferric derisomaltose-iron infusions would not be 
adequate to treat the enrollee's condition with the option to request another authorization for six additional 
infusions if needed. Therefore, the enrollee does not meet criteria for the requested amount of infusions. 
 
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 infusions of ferric derisomaltose-iron have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve 12 infusions of ferric derisomaltose-iron.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis treatment to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve dialysis treatment. You say that you want to stay close to your home and it 
would be hard to move to a more distant center. The Plan denied your request. The Plan says you can receive 
your care from a contracted facility that is available to offer the same services as the out-of-network provider.  
 
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 
dialysis treatment to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD) with frequent hospitalizations and 
inpatient arterial blood gas (ABG) showing carbon dioxide (CO2) retention. The records state the enrollee had 
failed bilevel positive airway pressure (bipap) and continuous positive airway pressure (cpap), but details are 
not provided. Other parts of the record state noncompliance.  If the problem was with tolerating the mask interface, then the same problem is likely to happen with a ventilator. There is no evidence establishing that 
intermittent daytime ventilation is beneficial in COPD. Treatment during sleep could be accomplished with 
bipap in the Average volume-assured pressure support (AVAPS) mode, and there is no documentation that this 
has failed as an outpatient. Medicare does not cover a home ventilator when used as bipap. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Touch Ultra 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 not covered. 
 
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 One Touch Ultra test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gas permeable contact lens. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee suffers from dry eye 
disease. The Plan denied your request. The Plan says the service is not covered 
 
The Plan must follow Medicare rules. The rules say that Medicare only covers eyeglasses and contact lenses 
under certain medical indications.  
 
We looked at the file and the rules. The records do not show that the requested lens is being requested for a 
covered indication. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a gas permeable contact lens.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a specialty bariatric hospital bed and a low-pressure mattress 
(E1399). 
 
You asked the Plan to pre-approve a specialty bariatric hospital bed and a low-pressure mattress. You say that 
the requested items are medically necessary. The Plan denied your request. The Plan says that the requested 
items does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 specialty bariatric hospital bed and a 
low-pressure mattress. Our reviewer says that the service is medically necessary. Our physician reviewer found 
the documentation does support that you have a condition that requires frequent positioning of the bed and 
mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in 
a way that an ordinary bed is not able to. You have congestive heart failure and lymphedema. The 
documentation indicates you are not able to move yourself easily and given your cardiac issues the head of the 
bed may need to be raised intermittently. 
 
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 specialty bariatric hospital bed and a low-pressure mattress have been met. 
Therefore, we decided that the Plan has to pre-approve a specialty bariatric hospital bed and a low-pressure 
mattress (E1399).  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 pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the office visit. You say that you want to see a provider outside the Plan's 
network. The Plan denied your request. The Plan says you have been directed to an equally qualified in-
network provider with an approved authorization. 
 
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 
an office visit to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for SNF care and can be treated in a lower level 
of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that 
skilled nursing facility (SNF) care is not medically necessary. Our physician reviewer found that 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 skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pathway 3G modular system-solid ramp. 
 
You asked the Plan to pre-approve a pathway 3G modular system-solid ramp. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a pathway 3G modular system-solid ramp.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
services are medically necessary. Our physician reviewer found you do have documented skilled nursing needs. 
You are receiving intermittent wound care and daily IV antibiotics. Daily skilled services are required to 
establish a maintenance program or to prevent deterioration of your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis. You say that you like the facility you are currently being treated at 
and have been there for six years. The Plan denied your request. The Plan says the services have been requested 
out-of-network and there is an in-network provider closer to your residence. 
 
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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a Dexcom G6 therapeutic CGM. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested item. 
 
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 G6 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from March 9, 2020, 
through March 14, 2020, billed with principal diagnosis code A41.9 and secondary diagnosis code R65.20. 
 You asked the Plan to pay for the inpatient care as billed. You say that this was billed with the correct DRG 
based on the enrollee's condition. The Plan denied your request. The Plan says the reported diagnoses of sepsis 
are not supported. 
 
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.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis code R65.20, defined as severe sepsis without septic shock. 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 as billed. Our reviewer 
says that the documentation does not support the reported principal and secondary diagnosis codes. Our 
physician reviewer found the enrollee is an 88-year-old man with a history of widespread stage IV metastatic 
prostate cancer, bilateral nephrostomy tubes, stage 3 chronic kidney disease, and hypertension. The enrollee 
presented with chills, weakness, and fatigue. It is documented that the enrollee was in no acute distress. The 
enrollee was admitted to the hospital with neutropenia, acute kidney injury on chronic renal disease, likely 
prerenal related to sepsis, and acute hyponatremic hypovolemia. The enrollee was not interested in any further 
chemotherapy. A review of the clinical documentation does not sufficiently support A41.9 and R65.20 as the 
principal and secondary diagnosis codes for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from March 9, 2020, through March 14, 2020, billed with principal 
diagnosis code A41.9 and secondary diagnosis code R65.20.