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

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the service you 
are requesting does not meet the requirements for approval. 
 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found this patient is at 
high risk for tumor recurrence as she has a history of stage IV colon cancer.  While it is true that she is beyond 
5 years after original diagnosis and treatment, the nature and extent of her disease places her at very high risk 
for recurrence.  For that reason, the requested MRI of the abdomen and pelvis is reasonable and should be 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have been met. Therefore, we decided that 
the Plan has to pre-approve magnetic resonance imaging (MRI).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine/Prilocaine 2.5% Cream. 
 
You asked the Plan to pre-approve this drug. You say that you need this cream to numb your arm. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lidocaine/Prilocaine 2.5% 
Cream.  
 
Benefits for this drug 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: 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 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. Although records document the enrollee is very limited functionally, provided records do 
not document a significant decline in the enrollees functional status compared to her recent baseline to 
necessitate daily inpatient skilled therapy services. The enrollee does not require the services on an inpatient 
basis, only in a skilled nursing facility setting. Records do not document that services in a long-term care 
facility on a part time basis are not 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter lift for a vehicle. 
 
You asked the Plan to pre-approve a scooter lift for a vehicle. You say that this device is medically necessary. 
The Plan denied your request. The Plan says this device is not covered because it is to be used outside your 
home. 
 
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 scooter lift for a vehicle.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 26, 2021, billed 
with codes 81206, 81162, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81404 and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are supported as necessary 
and were billed correctly. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules. In addition, some of these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 26, 2021, billed with codes 81206, 81162, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81404 and 81194.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve facet joint injection. You say that the enrollee's symptoms are originating 
from the right sacroiliac (SI) joint so this injection is recommended. The Plan denied your request. The Plan 
says the record does not indicate that the enrollee's pain is mostly in the low back and does not travel to other 
areas of the body. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered if certain 
criteria are 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 facet joint injection. Our reviewer says that the enrollee does not meet the Medicare criteria for a facet joint injection. Our physician reviewer found 
the enrollee has low back pain and possible sacroiliitis. This request is not medically necessary or reasonable 
and does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guidance for the radiation therapy. 
 
You asked the Plan to pre-approve ultrasound guidance for the radiation therapy. 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 ultrasound guidance for the radiation 
therapy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found certainly using ultrasound on a daily basis is not 
unreasonable, but to bill for daily simple simulations and/or Image-guided radiation therapy (IGRT) for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general), would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guidance for the radiation therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ultrasound guidance for the radiation therapy.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for revascularization of upper extremity arterial occlusion. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Medically necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided 
from January 31, 2022, to February 4, 2022. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of the secondary 
diagnosis code is supported. The Plan denied your request. The Plan says the billing of secondary diagnosis 
code, J96.01, Acute Respiratory Failure with Hypoxia is 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 secondary diagnosis code, J96.10, defined as 
Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. 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 an additional amount for the inpatient care. Our reviewer says that the 
diagnosis code is not supported. Our physician reviewer found the provided documentation did not support the 
billing of secondary diagnosis code, J96.01, Acute Respiratory Failure with Hypoxia.  
 
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 
an additional amount for the inpatient hospital care provided from January 31, 2022, to February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria 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 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
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 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. The enrollee is walking household distances with a rolling walker with minimal guard 
assistance and is supervision level for transfers. Provided records do not document a significant decline in the 
enrollees functional status to necessitate daily inpatient skilled therapy services. The enrollee does not require 
the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that 
services in the home with home health care or in a long-term care facility on a part time basis are not 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a handheld shower wand. 
 
You asked the Plan to pre-approve a handheld shower wand. You say that this is necessary for your medical 
condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
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 handheld shower wand.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the monthly supply allowance for a continuous glucose monitor (CGM) 
for date of service February 28, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that this was authorized by the Plan and has 
been billed and paid monthly. The total number of units was not exhausted. The Plan denied your request. The 
Plan says that payment has been made for 16 units of K0553 in the last 329 days. No further payment can be 
made as only 12 per year were approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has denied this claim indicating that more than 12 units were 
reimbursed in the past year. However, review of the documentation shows that the appealing supplier has 
regularly billed one unit monthly and has not exceeded the 12 units of the supply code per year. On two 
occasions, however, the Plan received and paid claims from a different supplier. For date of service December 
6, 2021, and February 21, 2022, the Plan paid out 3 units of the supply code to another provider, in spite of the 
fact that no more than one unit is payable on a single claim. We find that denial of payment to the appealing 
supplier based on payments made in error to another supplier is not appropriate. The denial of payment is not 
supported, as it would be the payments made to the second supplier that should be denied. Therefore, we 
decided that the Plan has to pay for the monthly supply allowance for a continuous glucose monitor (CGM) for 
date of service February 28, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is necessary for the enrollee's condition. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 home health physical therapy visits. 
 
You asked the Plan to pre-approve 5 home health physical therapy visits. 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 health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Medical records were requested, and therapy records were not received from the 
health plan. Without this information, the plan's denial is not able to be substantiated. Therefore, we decided 
that the Plan has to pre-approve 5 home health physical therapy visits.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission into the requested facility is 
medically necessary. The Plan denied your request. The Plan says the enrollee can remain in the current acute 
care location until no further acute level care is needed. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that are not available at the current 
health care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.