Persius/hicric huggingface dataset:
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation that you require skilled nursing services or skilled therapy 
services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to 
provide medically necessary and reasonable treatment safely and effectively. Records do not document the 
need for intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory 
care. There is no documentation that daily skilled services are required. You are walking household to 
community distances with a rolling walker with contact guard assistance and are contact guard assist for 
transfers and stand-by assist with most activities of daily living (but is maximum assist with lower body care). 
Provided records do not document a significant decline in your functional status to necessitate daily inpatient 
skilled therapy services. You do not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Records support those services in the home with home health care or on an outpatient basis are 
appropriate in this case. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 18, 2022, 
through March 24, 2022, and billed with secondary diagnosis code A41.9-sepsis, unspecified organism. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of A41.9. 
 
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 secondary diagnosis code A41.9-sepsis, unspecified 
organism. 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 hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the secondary diagnosis of 
A41.9, Sepsis. Our physician reviewer found the member had findings of tachycardia, leukocytosis with a left 
shift. The member had elevated creatinine and hydronephrosis requiring stent retrieval, bilateral percutaneous 
nephrostomy with infrared radiation, fluids, and antibiotics which led to improved controlled release. However, 
Sepsis 3 criteria was not met. With that being said, secondary diagnosis code A41.9-sepsis, unspecified 
organism is not the appropriate secondary diagnosis.  
 
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 inpatient hospital services provided on March 18, 2022, through March 24, 2022, and billed with secondary 
diagnosis code A41.9-sepsis, unspecified organism.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide. 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee cannot do simple tasks. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs and has an available and willing caregiver. 
 
 
 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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is recommended for the enrollee. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found medical guidelines do not support the use of proton beam therapy for routine 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve a lower limb prosthesis. You say that this document is intended to reiterate 
the medical necessity of use of the advanced vacuum pump feature with the enrollee's replacement left 
transtibial prosthesis. The Plan denied your request. The Plan says the request for a vacuum-assisted socket 
system does not meet Medicare criteria as reasonable and 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 a lower limb prosthesis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a left below the knee amputation. Based on the medical records 
provided, there is no documentation that the enrollee meets criteria for the requested vacuum pump, residual 
limb volume management and moisture evacuation system. Provided medical records from the enrollee's 
treating physician in this case make no mention of a need for the requested vacuum pump, residual limb 
volume management and moisture evacuation system. 
 
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 lower limb prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume 
management and moisture evacuation system (L5781).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transport services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve ambulance transport services to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have 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 
ambulance transport services to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. 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 covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have not tried and failed the required 
drugs. There is no documentation provided indicating that the Plans required drugs would likely be less 
effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and the other 
requested items/accessories (E0955, E1028, E1002, E1012, E2300, E2311, E2313, E2331, E2361, E2377, 
E2607 and E2620). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the request for this power wheelchair cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the enrollee does not have high risk for skin breakdown - the enrollee has had no skin breakdown in two 
years and the enrollee has been using a power chair for two years. No intermittent catheter or spasticity 
requiring special positioning. The enrollee does not require multiple power drives. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to 
and including 300 pounds (K0861) and the other requested items/accessories (E0955, E1028, E1002, E1012, 
E2300, E2311, E2313, E2331, E2361, E2377, E2607 and E2620).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance to be provided 
by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says 
there are in-network providers that are able to provide these services. Therefore, coverage criteria have 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 pneumatic compressor (E0652) and segmental pneumatic appliance for use with pneumatic compressor, full 
leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this type of injection is considered experimental /investigational. They have not been 
shown to be consistently safe and effective. Medicare does not allow payment for experimental/investigational 
procedures. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has bilateral knee pain. He is morbidly obese (BMI 49.7) and is not a candidate for 
knee replacement surgery due to his weight. He takes Gabapentin, Hydrocodone, Oxycodone and tramadol for 
pain. He has had viscosupplementation. The role of genicular nerve blocks and RFA is the subject of ongoing 
clinical trials. It is still considered experimental/ investigational at this time.  Therefore, the request is deemed 
not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging 
guidance, when performed (64454).
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 are requesting reconsideration for seven days of 
inpatient rehabilitation. The Plan denied your request. The Plan says criteria for admission to the IRF setting 
have 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 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
doesnt support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. 
The enrollee can receive further services at a lower level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has been hospitalized since 
March 15, 2023, for very severe acute and chronic hypercapnia respiratory failure. She was treated with a non-
invasive ventilatory support using BiPAP-ST with relative stabilization in clinical status. However, despite 
nearly 2 weeks of nightly NIV, she continues to have a markedly elevated PC02 of 75mmHg. Because of the 
difficulty in reducing PC02 levels, you are hoping to treat her more aggressively with noninvasive ventilator 
support. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease, restrictive ventilatory defect 
with paralyzed hemidiaphragm and possible mild pulmonary fibrosis and pulmonary hypertension. Provided 
records document that the home ventilator is being requested for use in intelligent volume assured pressure 
support (IVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with average 
volume assured pressure support (AVAPS) and a back-up rate.  As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 15, 2020, to 
October 28, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code N17.0, described as acute 
kidney failure with tubular necrosis. 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 hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed codes. Our physician reviewer found the documentation does not indicate that the treatment ordered 
by the treating medical providers supported a diagnosis code of N17.0.  
 
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 inpatient hospital services provided on October 15, 2020, to October 28, 2020, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo System. 
 
You asked the Plan to pre-approve a Barostim Neo System. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Barostim Neo System. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees 
clinical 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 a Barostim Neo System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo System.