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 it is felt that LTACH would be the best 
option. The Plan denied your request. The Plan says the clinical assessment does not support the expectation of 
a stay to be at least 25 days. 
 
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 the enrollee was admitted to the acute care hospital on 10/23/20 with hypoxic 
respiratory failure requiring intubation. The enrollee had a cardiac arrest on 10/28/20. A tracheostomy has been 
placed. On 11/10/20, the enrollee was getting out of bed and was on CPAP. Long term acute care hospitals 
(LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that 
are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital 
care, and acute care services have not been denied. The documentation does not support that the enrollee in this 
case requires services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. The requested LTACH services are/are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve musculoskeletal surgery (CPT Code 22899). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because there is little evidence in the medical 
literature to suggest that this is an appropriate procedure for the enrollees back pain. The Plan states that it is 
not an accepted standards of medical practice for the diagnosis or treatment of back pain and it is considered 
experimental and investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure remains experimental. More research is needed to show safety and 
efficacy. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve musculoskeletal surgery (CPT Code 22899).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires 3 hours of therapy a day 
provided by a multidisciplinary team. The Plan denied your request. The Plan says the enrollee does not require 
an interdisciplinary approach to rehab care. 
 
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 physician reviewer found 
that the enrollee is at a maximal assist level for sitting up, moderate assist for lying down, contact guard assist 
for standing up, and contact guard assist for ambulation using a rolling walker. The enrollee does not require 
the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient consultation (99245) with tertiary level 
Otolaryngologist. 
 
You asked the Plan to pre-approve the outpatient consultation. You say that you feel you should be able to see 
this provider because your cardiothoracic surgeon referred you to him and this is related to your surgery and 
ICU care at the same facility. The Plan denied your request. The Plan says this request is not considered 
reasonable and medically necessary be care can be provided by a doctor not part of a teaching hospital (tertiary 
care center. The plan has approved the enrollee to be seen by a non-tertiary level Otolaryngologist. 
 
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 outpatient consultation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has suffered from vocal cord paralysis due to compression and 
likely transection of the recurrent laryngeal nerve after a thoracic aneurysm repair. This a routine issue seen 
after heart and chest surgery, and can be managed by a general otolaryngologist. At this time, he does not 
require a tertiary consult to an academic ENT. The plan is offering an adequate alternative to the tertiary 
referral by referring him to a board-certified general ENT. The plan's referral to a non-tertiary provider meets 
the standard 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 the outpatient consultation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve outpatient consultation (99245) with tertiary level Otolaryngologist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services after November 8, 2020.You asked the Plan to pre-approve continuation of SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of admission, the enrollee required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of November 8, 2020 the enrollee did not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living.The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of careduring the period of care under review. He did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however his function had plateaued by November 8, 2020 and he did not require any further inpatient skilled rehab services. The enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. During the POC under review the enrollee required custodial services. The denial for further inpatient skilled care is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services after November 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are having injections and need this for the 
pain in your feet. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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. The Plan denied your request. The Plan says the 
enrollee does not have multiple complex medical needs. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care facility with gangrene on his right foot. 
He is status post femoral bypass, foot debridement, and has started IV antibiotics. An angiogram showed high 
grade stenosis and severe tibial disease with peroneal runoff. The enrollee appears to be improving overall, but 
does not require long-term antibiotics or frequent debridement or other daily physician services. He does not 
require services at the LTACH that are not already available at the current facility. Therefore, this request for 
LTACH services will be considered 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 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: 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 due to the enrollee's medical condition and the need 
for intensive therapy, IRF would be the best setting for this enrollee. The Plan denied your request. The Plan 
says the Medicare criteria for IRF care are not 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for gastrointestinal bleeding. Medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. The medical record 
supports a need for physical and occupational therapy, but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that this patient 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Bevacizumab and Pembrolizumab. 
 
You asked the Plan to pre-approve Bevacizumab and Pembrolizumab. You say that the medication is 
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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Bevacizumab and Pembrolizumab. Our 
reviewer says that the medication is not medically necessary. Our physician reviewer found the submitted 
documentation does not support that the requested drug combination is medically reasonable and necessary or 
safe and effective for you. 
 
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 and Pembrolizumab have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Bevacizumab and Pembrolizumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the documentation fails to indicate that 
the member's needs require continuous skilled nursing care, daily medical care, the availability of psychiatrists 
and physicians in other specialties 24 hours per day. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee in this case. It is not expected this enrollee would improve in a reasonable period of time as he does 
not have dangerousness to self or others, auditory or visual hallucinations, delusions and is not showing any 
behavioral issues. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve portable ventilator (E0466). You say that this device would enable you to 
carry out more activities of daily living. The Plan denied your request. The Plan says ventilators are only 
covered for enrollees who have conditions that require continuous respiratory support. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for enrollees 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 portable ventilator (E0466). Our 
reviewer says that the portable ventilator is not medically necessary. Our physician reviewer found coverage 
criteria for a home ventilator are not met. The enrollee does not meet criteria for BiPAP support at night. In 
addition, this open ventilator system is not a true ventilator, and is not an E0466 device. There is inadequate 
clinical evidence that it is beneficial in any lung disease. The open ventilator system is not medically necessary, 
and the denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable ventilator (E0466) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs a higher level of are to prevent returning back to the acute care hospital.The Plan denied your request. The Plan says the enrollee does not require physician supervision at least 3 times per week, or aggressive therapist 3 hours a day to regain function.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 physician reviewer found that the enrollee underwent cervical spine surgery. His post-operative course was complicated by development of an ileus,which has since resolved. His other chronic medical conditions are stable. He is weak and unsteady. He is walking 150 feet with a rolling walker with contact guard assistance, is minimum assist for transfers,and moderate to maximum assist for activities of daily living. The complexity of the enrollee'snursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrolleedoes require physical and occupational therapy services,but hedoes not require an intensive inpatient rehabilitation therapy 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there is no direct 
physician intervention required. 
 
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 physician reviewer found 
that the enrollee presented to the acute hospital with altered mental status, and history of a fall. The records 
indicate he was experiencing a gradual decline in function related to progression of Parkinsonism for about 
four weeks prior to the fall. He was treated in the hospital with neurology consultation and observation; brain 
imaging showed no acute findings. He is weak and unsteady, and is working with physical and occupational 
therapy. He is walking 5 feet with a rolling walker with moderate assistance, is at moderate assist for transfers, 
and maximum assist for some activities of daily living. He is reported to be medically stable for discharge. The 
complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. He does require physical and occupational 
therapy services, but he does not require an intensive inpatient rehabilitation therapy program. There is concern 
that he will not be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
 
 
 
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.