Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve services performed by a qualified physical therapist in the home health or hospice setting (G0151) and services performed by a qualified occupational therapist in the home health or hospice setting (G0152).
You asked the Plan to pre-approve the services performed by a qualified physical therapist and services performed by a qualified occupational therapist. The Plan denied your request. The Plan says that this request is 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 the services performed by a qualified physical therapist and services performed by a qualified occupational therapist. Our reviewer says that the requested home health services are medically necessary. Our physician reviewer found the documentation does support that you require skilled rehab services to provide treatment that is medically necessary. You require skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that you were hospitalized in April 2021, sent to a skilled nursing facility and then home. The documentation indicates that you continued to require assistance for mobility with a prior level of independence. Our physician reviewer also found that you could benefit from home health rehab services to provide care and establish 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 the services performed by a qualified physical therapist and services performed by a qualified occupational therapist have been met. Therefore, we decided that the Plan has to pre-approve services performed by a qualified physical therapist in the home health or hospice setting (G0151) and services performed by a qualified occupational therapist in the home health or hospice setting (G0152).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pelvis CT with angiography (74174).
You asked the Plan to pre-approve the pelvis CT with angiography. You say that you would like reconsideration because the requested CT is medically necessary. The Plan denied your request. The Plan says there is no rationale provided for the use of angiography
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pelvis CT with angiography. Our reviewer says that there is no clinical rationale for the requested Pelvis CT with angiography. Our physician reviewer found angiography is not medically necessary, nor the standard of care for the workup of hematuria or kidney stones. Angiography is typically used for evaluation of vascular abnormalities which per provided note and phone conversation there is no clinical evidence for or suspicion of. 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 pelvis CT with angiography have not been met. Therefore, we decided that the Plan does not have to pre-approve the pelvis CT with angiography (74174).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF stay.
You asked the Plan to pre-approve the SNF stay. You say that the enrollee has shown improvement with the current rehabilitation and you feel that continuing with sub-acute will benefit the enrollee greatly. The Plan denied your request. The Plan says movement to a skilled nursing facility is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF stay. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF stay.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging tomographic (SPECT) (CPT code 78452), for the enrollee.
You asked the Plan to pre-approve the testing. You say that the enrollee needs to have a nuclear stress test completed to rule out coronary artery disease as the etiology of their exertional shortness of breath as well as diastolic dysfunction. The Plan denied your request. The Plan says the Medicare rules have not been 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 the testing. Our physician reviewer found the review indicates that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage for Myocardial Perfusion Imaging tomographic (SPECT) (CPT code 78452). 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging tomographic (SPECT) (CPT code 78452), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 home health physical therapy (PT) visits.

You asked the Plan to pre-approve 12 home health PT visits. 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. 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 12 home health PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation doesn't support that you require additional skilled rehabilitation services to provide treatment that is medically necessary. You do not require skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. The previously authorized physical therapy visits should be enough to establish a home exercise program. The requested home health 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 12 home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 home health physical therapy (PT) visits.
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 an IRF admission is medically necessary for the enrollee to make a full recovery. The Plan denied your request. The Plan says acute inpatient rehabilitation is denied as not medically necessary.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and expandable controller (E2377, E2313, E2311) for a power wheelchair.
You asked the Plan to pre-approve the power seat elevation feature and expandable controller. You say that the features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that power seat elevation features are non-covered. Expandable controllers are covered when 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 power seat elevation feature and expandable controller. Our reviewer says that the requested wheelchair features are not medically necessary.
Our physician reviewer found the records do not show that the enrollee needs to control power functions through the joystick. The enrollee is capable of operating the standard switches. The power seat elevation function is not covered. 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 power seat elevation feature and expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and expandable controller (E2377, E2313, E2311) for a power wheelchair.
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 enrollee would benefit from IRF care as she has shown progress in both physical therapy and occupational therapy during her acute care hospital stay. The Plan denied your request. The Plan says the care and therapy needs that are required by the enrollee could be provided at an alternate setting, such as skilled nursing facility.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for cervical decompression surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

Explanation of decision
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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
There are no complex nursing or rehabilitation needs. you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Bevacizumab (Q5107).
You asked the Plan to pre-approve Bevacizumab. You say that the enrollee has no other options to improve his potentially life-threatening anemia. The Plan denied your request. The Plan says that Bevacizumab is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Bevacizumab. Our reviewer says that Bevacizumab (Q5107) is medically reasonable and necessary for the enrollee. Our physician reviewer found there is sufficient documentation in the medical literature to support that systemic Bevacizumab should be considered as a first-line therapy for refractory bleeding in patients with hereditary hemorrhagic telangiectasia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bevacizumab have been met. Therefore, we decided that the Plan has to pre-approve Bevacizumab (Q5107).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you require constant care to regain functionality to get back to normal. The Plan denied your request. The Plan says you do not meet IRF admission 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs.

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve the radiofrequency ablation. You say that you would like reconsideration
because you are experiencing nerve pain and it is affecting your colon and bladder. The Plan denied your
request. The Plan says the documentation does not include the percentage of relief from the initial procedure.

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 radiofrequency ablation.

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the pain relief from an RFA should last at least 6 months. The fact that the pain came back less than six months suggests other pain generators need to be examined. 

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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter tricuspid valve repair and and associated hospital stay.
You asked the Plan to pre-approve the transcatheter tricuspid valve repair and associated hospital stay. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of transcatheter tricuspid valve repair with the TriClip delivery system has not been established in the peer-reviewed medical literature.
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 transcatheter tricuspid valve repair and associated hospital stay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has tricuspid regurgitation and is enrolled in a clinical trial. Clinicaltrials.gov indicates that that the requested device is not approved by the Food and Drug Administration for use in this indication.
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 transcatheter tricuspid valve repair and associated hospital stay have not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter tricuspid valve repair and and associated hospital stay