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

 
We decided that the Plan does not have to pay for Freestyle Libre 2 reader and sensor kit (A4239, E2103). 
 
You asked the Plan to pay for Freestyle Libre 2 reader and sensor kit. You say that this was previously covered 
by your prior insurance. You do not use insulin, but you suffer from frequent episodes of hypoglycemia, and 
this helps you manage this condition. The Plan denied your request. The Plan says the enrollee is not on insulin 
and does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of Freestyle Libre 2 reader and sensor kit have not 
been met. Therefore, we decided that the Plan does not have to pay for Freestyle Libre 2 reader and sensor kit 
(A4239, E2103).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the device is medically necessary due to chronic respiratory failure, unspecified 
whether with hypoxia or hypercapnia 
 
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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has apparently had a home ventilator since April 2022, following a hospitalization. At that time, the 
enrollee was admitted with arterial blood gas (ABG) consistent with acute on chronic hypercarbic respiratory 
failure, with mental status changes. The enrollee improved on bilateral positive airway pressure (BiPAP). There 
is a diagnosis of chronic obstructive pulmonary disease (COPD), although there is no full pulmonary function 
testing report to confirm airways obstruction or assess severity. There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. Compliance reports over recent months do not meet minimum Medicare 
criteria for usage, of at least 4 hours per night for at least 70% of nights. It also appears the patient does not 
qualify for a home ventilator by Medicare criteria, because the ventilator is being used at settings that could be 
provided with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left atrial appendage closure (LAAC) surgical 
services (33268, 33518, 33508, 33533). 
 
You asked the Plan to pre-approve the service. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have atrial fibrillation. The Plan states the request is 
for left atrial appendage closure performed at the time of coronary artery bypass graft surgery (CABG) as a 
preventative measure should the atrium become thrombogenic at some point in the future. 
 
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 service. Our physician reviewer 
found at issue is the medical necessity of implanting a LAAC device in this enrollee in whom there is no 
documentation of atrial fibrillation. As such, guidelines would not support implantation of a LAAC in this 
setting. In summary, LAAC placement would not be considered reasonable or medically necessary in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the left atrial appendage closure (LAAC) surgical services (33268, 33518, 33508, 33533).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic for tooth number 19 and two retainer crowns 
for tooth number 18 and 20. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted when the Plan authorized four units of fixed 
dentures for tooth numbers 6, 7, 8 and 9. Therefore, we decided that the Plan does not have to pre-approve a 
pontic for tooth number 19 and two retainer crowns for tooth number 18 and 20.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the thoracic spine and an MRI of the brain. 
 
You asked the Plan to pre-approve an MRI of the thoracic spine and an MRI of the brain. You say that the 
enrollee would like reconsideration because the services are medically necessary. The Plan denied your 
request. The Plan says an MRI of the thoracic spine and an MRI of the brain is 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 an MRI of the thoracic spine and an 
MRI of the brain. Our reviewer says that an MRI of the thoracic spine and an MRI of the brain is not medically 
necessary. Our physician reviewer found that the enrollee has already had both MRIs of the thoracic spine and 
brain in late 2022. They came back normal. There is no medical need for repeating these normal studies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the thoracic spine and an MRI of the brain. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an MRI of the thoracic spine and an MRI of 
the brain.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 documentation does not support necessity for admission to an IRF. There's no 
medical complexity. The complexity of the enrollee's nursing, rehabilitation, and medical, needs (combined 
complexity) does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. While the enrollee may benefit from physical therapy (PT), and occupational therapy (OT), 
the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in a skilled 
nursing facility (SNF). 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that your physician wanted to continue home 
health physical therapy. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you had 
prior therapy, and the documentation does not reveal that you require the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. You have received instructions on home safety 
and a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the request is not covered by Medicare. 
 
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 radiofrequency ablation for denervation whether 
performed using traditional, cooled, or pulsed radiofrequency is considered investigational and therefore, not 
medically necessary. Based on this information, we decided that Medicare rules for coverage of radiofrequency 
ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency 
ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 the enrollee is chronically dependent at baseline. Daily skilled therapy is not 
indicated for the enrollee's condition. 
 
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: 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 you have had a very protracted hospital stay with complications of uterine cancer. At 
your baseline, you do squat pivot transfers from bed to power wheelchair. You are now only at modified 
independence for bed mobility and dresses in bed. No transfers evident in the record. Per chapter 8, there is no 
evidence you are willing and capable of participating in daily skilled therapy to address your transfer deficit. 
You are non ambulatory at baseline and dependent on a power wheelchair. 
 
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: 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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says the enrollee does not meet guidelines for coverage and no longer 
requires skilled services on a daily inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 7, 2022, to 
March 14, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly. The Plan denied your request. The Plan says principal diagnosis A41.9 and secondary 
diagnosis J96.01 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 J96.01 - 
acute 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 enrollee was sent to 
the emergency department (ED) for evaluation of nausea, vomiting and diarrhea. The enrollee subsequently 
developed a fever and was initiated on a sepsis protocol. The enrollee was initially thought to have pneumonia. 
The enrollee was confirmed to have a urinary tract infection (UTI) due to Pseudomonas. There is no evidence 
of hemodynamic instability or organ failure. There is no evidence of respiratory failure. Without the entire 
medical record, the presence and sequencing of diagnoses cannot be fully determined. However, the 
documentation does not support the presence of sepsis or respiratory failure. Additionally, it appears that UTI 
should be sequenced before pneumonia. As such, the billing 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 March 7, 2022, to March 14, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from July 25, 2022, to July 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99233 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the CPT code 99233. The documentation available for review does not support that the enrollee 
developed a significant complication or that medical decision making of high complexity was needed for the 
dates in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered from July 25, 2022, to July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields, along with superficial radiotherapy delivery (G6001). 
 
You asked the Plan to pre-approve radiation therapy. You say that the treatment is necessary for the enrollee. 
The Plan denied your request. The Plan says US-IGRT is not medically necessary for superficial radiation 
therapy. The request does not meet the Medicare or health plan coverage criteria. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 enrollee for which the target 
lesion can be seen on the skin to assist in daily set up. Certainly, using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound though that 
in and of itself does not mean that daily imaging is necessary but simply that the device was designed to 
incorporate this functionality. 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) is not necessary. The decision is unfavorable as 
billing for daily IGRT 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 radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasonic guidance for placement of radiation therapy fields, along with superficial 
radiotherapy delivery (G6001).