Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 27, 2021, 
to August 3, 2021, billed with diagnosis related group (DRG) code 871. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 871. The Plan denied your 
request. The Plan says DRG 871 is not supported as the diagnosis of Sepsis unspecified organism. 
 
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. 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 billed with DRG 871. Our reviewer says that the submitted DRG is not supported. Our physician 
reviewer found while it is acknowledged that the records include a physician-documented diagnosis of sepsis, 
and that Systemic Inflammatory Response Syndrome (SIRS) signs were present along with an elevated lactic 
acid, the clinical findings in the record do not sufficiently support the diagnosis of sepsis based on Sepsis 3 
criteria. The medical records do not support the billing of Sepsis unspecified organism. Our reviewer also 
found that DRG 194 would be more appropriate.  
 
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 July 27, 2021, to August 3, 2021, billed with diagnosis related 
group (DRG) code 871.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the next generation sequencing testing provided on December 30, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that the testing 
is not a covered benefit. 
 
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. 
 
This testing was provided to a patient with a solid tumor. The FDA approval notice indicates that this panel is 
approved for solid tumors. No other valid denial rationale was presented by the Plan. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for the next generation sequencing testing provided on 
December 30, 2021.  
 
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 a FreeStyle Libre 2 Sensor Kit, continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are trying to get the enrollee's sugar under 
control. You also say that the enrollee will need to test multiple time per day in order to adjust medications. 
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 and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 
Sensor Kit, continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 23, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this claim has been denied in error, and you would like it to be reprocessed for payment. The Plan denied your 
request. The Plan says the information submitted does not support criteria for ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the documentation does not support that the 
ambulance transport was medically reasonable and necessary for the enrollee. Our physician reviewer found 
the documentation does not support that other means of transport (such as stretcher van, wheelchair van) were 
contraindicated for this enrollee on January 23, 2022. Our reviewer found that the documentation does not 
support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a 
fully equipped ambulance could provide for safe transport on January 23, 2022. Our physician reviewer also 
found that there was a closer facility that was appropriate to treat the enrollee. 
 
 
  
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on January 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ottobock-Genium X3 adaptive microprocessor-
controlled swing and stance phase knee prosthesis coded as L5999 and K0108. 
 
You asked the Plan to pre-approve the prosthesis. You say that a properly designed prosthetic limb is the only 
answer that will help you return to your prior level of function and activities of daily living The Plan denied 
your request. The Plan says this durable medical equipment is not consistent with standards of care as a 
marginal benefit in function of this service over other prosthetic knees is not established. 
 
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 prosthesis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a new prosthetic is supported by the documentation provided. However, detailed 
documentation is not evident regarding the need for the requested prosthetic, Ottobock-Genium x3, over other 
conventional prosthetic knees without microprocessor control or other microprocessor-controlled as he 
currently has. The Ottobock-Genium x3 was recommended overwhelmingly so that the enrollee may go 
swimming and/or to the beach. These would not be medical indications but would be considered a convenience 
to the enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested Ottobock-Genium x3 
adaptive microprocessor-controlled swing and stance phase knee prosthesis (L5999 and K0108), in this case, is 
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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ottobock-Genium X3 adaptive microprocessor-controlled swing and stance phase knee 
prosthesis coded as L5999 and K0108.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 18, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you would either like payment or the ability to bill the enrollee for these services. The Plan denied your 
request. The Plan says the information provided does not support ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the documentation does not support that the 
ambulance transport was medically reasonable and necessary for the enrollee. Our physician reviewer found 
the documentation does not support that other means of transport (such as stretcher van) were contraindicated 
for this enrollee on January 18, 2022. Our reviewer also found that the documentation does not support that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped 
ambulance can provide for safe transport on January 18, 2022.  
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical collar (L0180) provided on March 16, 2022. 
 
You asked the Plan to pay for a cervical collar. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a cervical collar (L0180) provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a truss, single with standard pad provided on March 5, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a truss, single with standard pad. You say that you called ahead of time to 
confirm for a DME item and was never advised that you had to use a contracting provider. The Plan denied 
your request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a truss, single with standard pad provided on 
March 5, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair (PWC) with multiple power options, 
including power tilt and recline seat system with power elevating leg rests, skin protection/position seat 
cushion and an expandable controller with related electronics and hardware. 
 
You asked the Plan to pre-approve the Group 3 PWC as requested. You say that it is felt that this type of PWC 
is medically necessary. The Plan denied your request. The Plan says that the documentation does not show that 
both power tilt and recline are medically necessary. As such, the requested PWC base code is not supported. As 
such, none of the other requested components are necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC base with multiple power options 
requires that the criteria for power tilt and recline seating be met. The Medicare rules section of this decision 
details the criteria for these power seating systems.  
 
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 Group 3 PWC as requested. Our 
reviewer says that the requested PWC with all requested accessories is medically reasonable and necessary 
based on the documentation. Our physician reviewer found the enrollee is a male with a past medical history of 
traumatic brain injury with right sided spastic hemiparesis and weakness of both arms. He had previously been 
using a PWC that is no longer functioning.  
 
The clinical documentation and information directly from the Plan confirm that the enrollee does have an 
inability to relieve pressure from a weight shift due to his hemiparesis. For this reason, it is found that a group 3 
power wheelchair with power tilt, recline and elevating leg rests is medically necessary. It is also documented 
that the enrollee has bilateral arm weakness with poor range of motion. This supports that an expandable 
controller is medically necessary to use the power seating options. 
 
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 Group 3 PWC as requested have been met. Therefore, we decided that the 
Plan has to pre-approve a Group 3 power wheelchair (PWC) with multiple power options, including power tilt 
and recline seat system with power elevating leg rests, skin protection/position seat cushion and an expandable 
controller with related electronics and hardware.  
 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee could be safely and effectively treated at a skilled level of nursing care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our 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 a stroke and surgical repair of an ankle fracture after a fall. The enrollee's medical problems 
are stable. 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 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Device. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has congestive heart failure 
deemed refractory to optimal medical therapy. While clinical studies led to Food and Drug Administration 
(FDA) approval in 2019, the Optimizer Smart Device remains the subject of multiple studies examining long-
term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the 
current time, the device is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Optimizer Smart Device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can be treated with a bi-level positive airway pressure (BiPAP) 
device. 
 
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 requested portable ventilator is not medically necessary. Our physician reviewer found although the 
enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), there are no pulmonary function 
tests documented in the submitted records. The enrollee may benefit from a bi-level positive airway pressure 
(BiPAP) device with average volume-assured pressure support during sleep, but Medicare does not cover a 
home ventilator when used as a BiPAP device.  
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 (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. The Plan denied your request. The Plan says the SNF 
admission is not medically necessary. 
 
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 a SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found 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 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 a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a skilled nursing facility (SNF) admission.