Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) and segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the DME is not 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 durable medical equipment (DME). 
Our physician reviewer found the enrollee has lymphedema extending onto the chest, trunk and/or abdomen 
that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal 
lymphedema has failed to improve with a four-week trial. The review has determined that the requested PCD 
coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen does not meet all of 
the requirement. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) and segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic arterial embolization. 
 
You asked the Plan to pre-approve prostatic arterial embolization. You say that the enrollee meets the criteria 
for this procedure. The Plan denied your request. The Plan says that this procedure 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 prostatic arterial embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that prostatic arterial embolization is considered an experimental technique 
to treat symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible short-term 
safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical 
trial setting due to the heterogeneity in the available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, and higher clinical failure rate 
compared with more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostatic arterial embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve prostatic arterial embolization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microprocessor-controlled ankle-foot system for a 
lower limb prosthesis (L5973 x2). 
 
You asked the Plan to pre-approve the foot system. You say that these feet would provide enhanced stability 
and safety.  The Plan denied your request. The Plan says K3 feet are not necessary for the approved prosthesis. 
 
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 foot system. Our physician reviewer 
found the L5973 (x 2) microprocessor-controlled ankle-foot system for a lower limb prosthesis exceeds the 
enrollee's functional needs and is not medically necessary per LCD L33787. The requested ankle foot system is 
not medically necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member as the enrollee's current feet are still under warranty and the documentation does not 
reveal that the current feet require repair or that there is a physiologic change requiring new feet. 
 
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 foot system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the microprocessor-controlled ankle-foot system for a lower limb prosthesis (L5973 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 23, 2021, to 
June 26, 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 the 
assignment of the diagnoses codes are valid and supported by the documentation. You say that DRG 871 
should be reconsidered.  The Plan denied your request. The Plan says diagnosis codes A41.9 and N17.9 are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 - Sepsis, unspecified organism and N17.9 - 
Other acute kidney failure. 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 physician reviewer found on presentation, the enrollee's vital 
signs revealed blood pressure 166/65, temperature 101.9 degrees, heart rate 108, respiratory rate 24 and oxygen 
saturation 98 percent. The chest x-ray showed pneumonia and thus, antibiotics were administered. The enrollee 
was hemodynamically stable (no hypotension) on admission and during the stay. The enrollee was alert and 
oriented to time, place, and person on admission and during the stay. The bilirubin and platelet levels were 
normal. The enrollee did not have any significant hypoxia during the hospital stay. The mildly elevated 
creatinine was due to dehydration which improved with intravenous fluids and was not attributed to sepsis. In 
addition, the blood culture was negative. The review has determined that the documentation did not support 
diagnosis codes A41.9 and N17.9.  
 
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 June 23, 2021, to June 26, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 11, 2021, 
to September 15, 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 you 
provided supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. The 
Plan says diagnosis code J96.21 remains 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 J96.21- acute and chronic respiratory failure with 
hypoxia. 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 physician reviewer found the Health Plans denial should be upheld. The enrollee 
was hospitalized with shortness of breath and treated for a chronic obstructive pulmonary disease (COPD) 
exacerbation. The enrollee does use oxygen at baseline. There is no evidence that the enrollee had acute 
respiratory failure or was more hypoxic than enrollee's baseline. The identified blood gases appear to be venous 
in origin. As such, the billing of J96.21 is not supported.  
 
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 September 11, 2021, to September 15, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that due to your lung cancer, it is 
too difficult to carry around the provided portable oxygen tanks as they are too heavy to carry around. The Plan 
denied your request. The Plan says there is no indication your current oxygen equipment is not meeting your 
medical needs or activities of daily living in or around the home.  
 
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 portable oxygen concentrator. Our 
physician reviewer found it appears that this is an initial order for supplemental oxygen. Medicare does not 
cover a portable oxygen concentrator as the sole oxygen source. The portable concentrator cannot be used in 
place of a stationary oxygen concentrator. In addition, there is no documentation that the oxygen saturation 
(SpO2) can be maintained above 91 percent using an oxygen conserving device with a flow rate of 1 to 4 liters 
a minute.   
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy (0394T). 
 
You asked the Plan to pre-approve electronic brachytherapy. 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the pathology report showed a squamous cell carcinoma in situ with positive 
margins. the records do not indicate that she has undergone clinical staging or been considered for excision of 
the lesion. The review has determined that the items/services at issue in this case are 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy (0394T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 25, 2022, 
to March 31, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed you would be 
charged a copayment for your SNF stay. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $1,316 for a SNF stay ($188 per day x 7 days = $1,316). This item/service falls 
within the SNF care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided 
from March 25, 2022, to March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV).  
 
You asked the Plan to pre-approve the requested NIV. You say that the enrollee requires this NIV due to 
respiratory failure.  The Plan denied your request. The Plan says the NIV requested does not meet criteria for 
approval. 
 
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 the requested NIV. Our reviewer says that the requested NIV is not medically reasonable and necessary.  Our physician reviewer found the enrollee 
underwent thoracic surgery for a thoracic aortic dissection in January 2023 and has had recurrent pleural 
effusions requiring thoracocentesis since then. The enrollee was hospitalized in February with acute respiratory 
failure requiring intubation. The hospital record shows no history of asthma or COPD.  
 
There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee improved after 
therapeutic thoracentesis. There is no arterial blood gas (ABG) testing done while stable to document chronic 
carbon dioxide retention. There is no evidence that bilevel positive airway pressure (BiPAP) has been tried and 
failed as an outpatient. Moreover, a compliance report covering February 9 to March 22, 2023, shows the 
device is being used for at least 4 hours per day for only 7% of days. As such, the device is not shown to be 
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 the requested NIV have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a non-invasive ventilator (NIV).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 reader device.  
You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor (CGM). 
Our physician reviewer found this enrollee is not using insulin and is not having low blood glucose levels 
(BGs) that the reviewer is told of. The enrollee is not using medications that typically cause low BGs; 
therefore, criteria are not met at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continuous glucose monitor (CGM) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Freestyle Libre 2 reader device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion from an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are requesting to see an out-
of-network provider for a second opinion The Plan denied your request. The Plan says the services you are 
requesting are available in your area from in network providers. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found there is no 
indication for an out-of-network second opinion. You can undergo the second opinion within his network. The 
review has determined that the second opinion by an out-of-network provider is not medically necessary as you 
can obtain a second opinion from an in-network provider. 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve a second opinion from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism.  
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that you can rise from a chair 
with contact guard assistance. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the arm.  
 
You asked the Plan to pre-approve the MRI of the arm. You say that the services are medically necessary. The 
Plan denied your request. The Plan says imaging requires six weeks of provider directed treatment to be 
completed before services can be approved.  
 
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 the MRI of the arm. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found testing for trigger finger and carpal 
tunnel syndrome has been negative. The x-rays showed mild degenerative osteoarthritis. No electromyography 
(EMG) study has been done. No serological workup for collagen vascular disease has been done. No 
conservative physical therapy has been done. The medical necessity of the requested MRI for both hands has 
not been established in the submitted records. 
 
 
 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 MRI of the arm have not been met. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance imaging (MRI) of the arm.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 1, 2023, 
to January 5, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed the insurance 
coverage was ending or you would have gone home because you are unable to afford the cost share. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $752 for a SNF stay ($188 per day x 7 days = $752). This item/service falls within 
the SNF care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from 
January 1, 2023, to January 5, 2023.