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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of a LTACH admission.
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 is currently undergoing treatment at an acute care hospital (ACH) for failure to thrive and infectious diarrhea. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy services.
You asked the Plan to pre-approve the physical therapy services. You say that there is no way for you to adjust your back or neck the way a physical therapist does. The Plan denied your request. The Plan says you do not need a skilled therapy provider to do the requested services.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our physician reviewer found that the requested therapy is generally not accepted as specific and effective therapy for your condition. You have had prior PT, and the documentation is not clear that this therapy has been effective for your condition. The records do not include a physician progress note indicating a need for further additional skilled therapy. The documentation does not reveal extenuating factors that indicate you are unable to safely and effectively transition to a home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not required to establish, design and/or deliver a program to maintain your current condition, or to prevent or slow further deterioration. Therefore, the requested services are 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 the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health skilled nursing services. The Plan denied your request. The Plan says the enrollee has no more skilled nursing needs.
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 skilled nursing services. Our physician reviewer found that the enrollee has had home instruction on disease management, medications, and monitoring. The enrollee's medication condition is stable with stable vital signs. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, to establish/perform a maintenance program to maintain her condition or prevent deterioration. Her condition does not require the requested additional skills nursing visits to maintain her chronic medical conditions. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total hip arthroplasty (THA) surgery.
You asked the Plan to pre-approve THA surgery. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that total hip arthroplasty (THA) surgery will be covered when the enrollee meets one or more of certain specific criteria. 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 THA surgery. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested THA surgery. Our physician reviewer found the enrollee presents with recalcitrant left lateral hip and groin pain. Functional limitations are noted in ambulatory tolerance. Clinical exam findings have documented limited and painful range of motion. She was status post left hip arthroscopy with iliotibial band release, abductor debridement, and bursectomy on January
21, 2020 with only temporary pain relief. She has failed recent conservative treatment, including activity modification, medications, physical therapy, and home exercise program for at least 3 months. The surgeon has reported X-Ray findings of Kellgren-Lawrence moderate osteoarthritis of the left hip. Under consideration is a request for left total hip arthroplasty. Medicare criteria have not been met. The enrollee does not meet one or more of the coverage criteria for total hip arthroplasty. There is no evidence that this enrollee has advanced degenerative joint disease based on the May 21, 2020 X-Ray report documentation of moderate osteoarthritis or the May 5, 2020 Magnetic Resonance Imaging (MRI) report of mild left hip degenerative arthropathy. The surgeon reports moderate osteoarthritis. Therefore, this request for left total hip arthroplasty would not be considered medically necessary and reasonable 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 THA surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve total hip arthroplasty (THA) surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz intra-articular knee injections (J7321).
You asked the Plan to pre-approve Supartz intra-articular knee injections. You say that the requested injections are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when specific criteria is 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 Supartz intra-articular knee injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found in this case, the enrollee has symptoms of osteoarthritis of bilateral knees but the clinical diagnosis has not been supported by radiologic evidence of osteoarthritis. In addition, other diagnoses have not been excluded by appropriate evaluation and management services. There is no documentation indicating the enrollee has failed at least three months of conservative therapy such as anti-inflammatory medications and physical therapy or previous steroid injections. The review has determined that the enrollee does not meet the coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz intra-articular knee injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz intra-articular knee injections (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on November 27, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that an LSO is covered when specific criteria are met.We looked at the file and Medicare rules. There is no documentation to support that the LSO meets the Medicare criteria for coverage. 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 pay for the lumbar-sacral orthosis (LSO) rendered on November 27, 2019.
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 this level of care would be best to allow her to optimize her dosage of medications and receive aggressive therapies to address her functional decline. The Plan denied your request. The Plan says the enrollee's medical condition does not warrant an acute inpatient stay or an intensive therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee is a female seen on 5/20/2020 by her neurologist for Parkinson's disease with increasing functional and memory decline. She had a stroke in December 2018 and had a rehab stay and had HH for a brief period. Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The patient is generally medically stable with Parkinson's disease with falls and functional and memory decline with no recent neurological or Orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or need for acute rehab nursing care. She requires minimal assist for transfers and standby assist for walking and bed mobility. While the patient may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary since you are unable to walk due to medications. 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer assisted navigation to be used during a total knee replacement.You asked the Plan to pre-approve the computer assistance. You say that it is felt that this should be approved.The Plan denied your request. The Plan says while the knee replacement has been approved, the use of computer assistance is not reasonable and 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 the computer assistance. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found computer-assisted total knee replacement surgery is experimental. More research is needed to show that the computer technique is more effective than conventional open knee replacement surgery. It is not medically needed.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 computer assistance have not been met.Therefore, we decided that the Plan does not have to pre-approve computer assisted navigation to be used during a total knee replacement.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 home physical therapy visits (G0151).
You asked the Plan to pre-approve 10 home physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 10 home physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found records do not provide objective evidence that points to the enrollee as being home-confined. There is indication the member can ambulate household distances. There is no indication continued home health therapy will provide significant benefit and/or that the enrollee could not now transition to an outpatient 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 10 home physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 home physical therapy visits (G0151).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of a LTACH admission.
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 is currently undergoing treatment at an acute care hospital (ACH) for COVID-19. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee does not appear to be currently appropriate for, or to be undergoing, ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 physical therapy visits.
You asked the Plan to pre-approve 16 physical therapy visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 16 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had extensive therapy for your chronic condition per documentation. The records do not demonstrate that 16 more visits with the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You should be able to transition to an independent home exercise program after 28 visits of therapy. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 16 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy, special physics consult, and special treatment procedure.
You asked the Plan to pre-approve proton beam therapy, special physics consult, and special treatment procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 proton beam therapy, special physics consult, and special treatment procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while some may argue that it is standard practice to treat prostate cancer with proton therapy, both ASTRO and the NCCN guidelines recommend against routine use of proton therapy. Proton therapy would arguably exceed the need for this 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 proton beam therapy, special physics consult, and special treatment procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy, special physics consult, and special treatment procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that
documentation does not support that care is too complex to be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF services.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.