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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 10, 2021, 
to December 13, 2021, 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 these 
services were medically necessary and are supported in the record. The Plan denied your request. The Plan says 
DRG 871 is not appropriate as the diagnoses of sepsis, unspecified organism (A41.9) and acute respiratory 
failure with hypoxia (J96.01) are not supported in the medical record. The Plan argues that DRG 194 is more 
appropriate in this case. 
 
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 sepsis, unspecified organism (A41.9) and acute 
respiratory failure with hypoxia (J96.01). 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 diagnoses of sepsis, 
unspecified organism (A41.9) and acute respiratory failure with hypoxia (J96.01) are not supported in the 
medical record for this inpatient admission. Our physician reviewer found that the criteria for reporting sepsis 
and respiratory failure are not met, and there was no clinical or laboratory evidence of sepsis or respiratory 
failure noted. The medical records did not support the billing of sepsis, unspecified organism (A41.9) and acute 
respiratory failure with hypoxia (J96.01).  
 
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 December 10, 2021, to December 13, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has been discharged and 
needs to go to a safe place to take care of their wounds. The Plan denied your request. The Plan says the criteria 
for LTACH admission were not met and the enrollee's medical needs are being met at the current acute setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission after October 31, 2022. 
 
You asked the Plan to pre-approve inpatient admission after October 31, 2022. You say that the services are 
medically necessary. 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 inpatient admission after October 31, 
2022. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found case management has been working on placement since 
November 10, 2022. Continued inpatient admission is not 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 inpatient admission after October 31, 2022, have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient admission after October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin protection wheelchair seat cushion (E2622) and a 
solid seat insert (E0992). 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that your provider is requesting the cushion 
to aide in healing of your stage 3 pressure ulcers. You do not have a wheelchair and will be using the cushion 
on a regular chair so you will need a solid support insert. The Plan denied your request. The Plan says the 
request is denied because the requested wheelchair accessories are not requested to be used with a wheelchair. 
The cushion and seat insert are requested for use on a regular chair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say that the requested items are covered if criteria are 
met. Your records show that you do not have a manual or power wheelchair. The records also show that you 
intend to use the requested cushion and insert on a regular chair. Therefore, you do not meet criteria for 
approval of these items. Based on this information, we decided that Medicare rules for coverage of wheelchair 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a skin 
protection wheelchair seat cushion (E2622) and a solid seat insert (E0992).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the right L5 radiofrequency ablation. 
 
You asked the Plan to pre-approve the surgical procedure. You say that per the denial there is no update of pain 
relief so you have made a note on the clinicals where it is documented so you may get this appeal processed. 
The Plan denied your request. The Plan says that the records do not show that the enrollee meets the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the surgical procedure. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic axial low back pain. The enrollee underwent diagnostic 
medical branch blocks, and the note clearly states 80% pain relief was achieved from the initial diagnostic 
blocks. 
 
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 surgical procedure have been met. Therefore, we decided that the Plan has 
to pre-approve the right L5 radiofrequency ablation.  
 
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 image-guided radiation therapy (IGRT) services. 
 
You asked the Plan to pre-approve IGRT services. You say that this procedure is considered medically 
reasonable and necessary. The Plan denied your request. The Plan says there is not enough evidence that this 
type of radiation therapy guidance is needed or effective for your skin cancer. 
 
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 IGRT services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that radiation is a standard approach to the treatment of skin cancer, and is often preferred over 
surgery when resection is likely to result in unacceptable morbidity or cosmesis. In this case, the treatment 
itself is not disputed in this case but rather the need for image guidance. 
 
IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as 
to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when 
generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this patient for which 
the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally 
not a need for IGRT unless deep structures are being treated. 
 
Using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily 
simple simulations and/or 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- 
citations below) is not 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 IGRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine transportation trip for a total of 105 miles. 
 
You asked the Plan to pre-approve these services. You say that you need additional mileage for a neurology 
appointment. The Plan denied your request. The Plan says the request exceeds the mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when .  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a routine transportation trip for a total of 105 miles.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiogram (MRA) of the brain, 
MRA of the spinal cord, and soft tissue magnetic resonance imaging (MRI) of the orbit, face, and neck. 
 
You asked the Plan to pre-approve MRA of the brain, MRA of the spinal cord, and MRI of the orbit, face, and 
neck. 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. 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 MRA of the brain, MRA of the spinal 
cord, and MRI of the orbit, face, and neck. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found in this case, the record indicates that the enrollee has new onset seizures. The 
requested services are not medically necessary and reasonable for the diagnosis and treatment for the enrollee's 
clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRA of the brain, MRA of the spinal cord, and MRI of the orbit, face, and neck 
have not been met.   
Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance angiogram (MRA) of 
the brain, MRA of the spinal cord, and soft tissue magnetic resonance imaging (MRI) of the orbit, face, and 
neck.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 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 foot orthotics/inserts (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that it is necessary that you are fitted for a bilateral 
custom orthotics at this time as a prefabricated orthotic will not be sufficient with pes planus, hindfoot valgus 
deformity with fat pad atrophy. This condition is expected to be longstanding. 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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics/inserts (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you need this to be covered, you had just moved and 
needed care. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 an office visit provided on April 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting admission to a SNF to reach your 
independent goals with the assistance of a skilled therapist. The Plan denied your request. The Plan says you do 
not meet the criteria for SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not 
meet the criteria for severity of illness or intensity of service on an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging, of the pelvis; without 
contrast material(s), followed by contrast material(s) with further sequences (72197) and 3 dimensional (3D) 
pictures (76377). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has prostate cancer that has been treated. The record indicates that the enrollee's 
prostatic specific antigen had decreased and he is asymptomatic. The provided record does not establish that 
the requested services are medically necessary and reasonable for the diagnosis and treatment for the enrollee's 
clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested services 
cannot be recommended. 
 
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 magnetic resonance imaging, of the pelvis; 
without contrast material(s), followed by contrast material(s) with further sequences (72197) and 3 dimensional 
(3D) pictures (76377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture services. You say that the provider at issue is a network 
provider. The Plan denied your request. The Plan says rules for coverage for OON care 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 acupuncture services to be provided by an 
OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dornase Alfa (Pulmozyme Solution) (J7639). 
 
You asked the Plan to pre-approve the Pulmozyme Solution. You say that the enrollee has been stable on 
Pulmozyme, and will need to continue using it while the stent is in place. The Plan denied your request. The 
Plan says Dornase Alfa is not approved because it is not Food and Drug Administration (FDA) approved for 
the enrollee's condition. 
 
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 the Pulmozyme Solution. Our physician 
reviewer found the documentation did not support that the Pulmozyme Solution is medically reasonable and 
necessary for the enrollee. Our reviewer also found that the documentation does not support that the 
Pulmozyme Solution is safe and effective for 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 Pulmozyme Solution have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Dornase Alfa (Pulmozyme Solution) (J7639).