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 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 in this case, ongoing care needs include oxygen supplementation, surveillance
laboratory studies, wound care, tube feedings, and therapy services. 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
he is currently receiving care. There are no required medical services identified that are available at the
LTACH, that are not available at the current health care setting being offered by the health plan. Consequently,
the requested LTACH services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee can be safely treated at a SNF level of 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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found 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. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not
require transfer to the LTACH.
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 is currently undergoing treatment at an ACH for pneumonia. The
enrollee was transiently intubated/ventilated, but has since been extubated and is no longer on a ventilator.
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 admission to a long term acute care hospital (LTACH).
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 denial of admission to LTACH would be detrimental to the enrollee's progress. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 does not require services at the LTACH that are not already available at the current acute care facility. Therefore, continued care at the current facility until the enrollee is able to discharge to a lower level of care is most appropriate. 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: Favorable

We decided that the Plan has to pre-approve knee arthroscopy with meniscectomy for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no documentation submitted of any type of mechanical symptoms in the knee.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with complaints of persistent left knee pain. Pain interferes with functional mobility. Clinical exam findings have documented medial joint line tenderness and apprehension with McMurray's test. There is imaging evidence of a complex medial meniscus tear with large meniscal cyst. She has reportedly failed over 7 months of conservative treatment. Under consideration is a request for left knee arthroscopy with meniscectomy. Current evidence based medical literature supports generally supports meniscectomy for middle aged patients with meniscal symptoms, even in the absence of mechanical symptoms. In this case, there are clinical findings consistent with imaging evidence of a complex tear and a large symptomatic meniscal cyst. Therefore, this request for left knee arthroscopy with meniscectomy is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have been met.Therefore, we decided that the Plan has to pre-approve knee arthroscopy with meniscectomy for the enrollee.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 transthoracic echocardiography (TTE) services.
You asked the Plan to pre-approve the transthoracic echocardiography services. You say that The Plan denied your request. The Plan says records are required for the request to be approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that information must be submitted to clarify that Medicare criteria for coverage have been met. We looked at the file and Medicare rules. The case file shows that no medical records were provided to support that the criteria for coverage have been met. The case file shows that the Plan made reasonable attempts to obtain this necessary documentation. Without medical records, the medical necessity of the requested service has not been established. Based on this information, we decided that Medicare rules for coverage of the transthoracic echocardiography services have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional physical therapy visits for the enrollee.You asked the Plan to pre-approve the additional visits. You say that this is medically necessary, due to testing and function deficits.The Plan denied your request. The Plan says this is 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 the additional 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 the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The patient has an extensive therapy history dating back to at least 3/13/20. She has made progress in therapy and the records do not indicate she requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The patient has had extensive therapy and was trained in a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 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 the additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve eight additional physical therapy visits for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.You asked the Plan to pre-approve this drug. You say that this medication is medically necessary.The Plan denied your request. The Plan says that this is not covered by the Plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Eliquis for the enrollee.Benefits for this drug may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveten additional sessions of physical therapy.You asked the Planto pre-approvethe additional sessions. You say that you have pain from nerve damage and muscular strain.The Plandenied your request. The Plansaysthe plan has no contractual obligation to cover services that 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 the additional sessions. 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 the requested therapy is not generally accepted as specific and effective therapy for your condition. You have chronic back pain. The documentation does not reveal significant overall objective functional improvement from prior therapy and the records do not indicate that you require the unique skills of a professional therapist to safely and effectively provide treatment. The services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. You have had extensive therapy, and should be ableto transition to an independent home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program tomaintain your condition or to prevent and 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 the additional sessions have not been met.Therefore, we decided that the Plandoes not haveto pre-approveten additional sessions of physical therapy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychological testing (CPT 96136) and psychological
testing evaluation (CPT 96130) services.
You asked the Plan to pre-approve the psychological testing and psychological testing evaluation services. You
say that the records provided support the need for the requested services. The Plan denied your request. The
Plan says medical information received shows that the enrollee does not have a documented cognitive
impairment. The Plan says that the criteria for coverage of the requested services have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the psychological testing and
psychological testing evaluation services. Our reviewer says that the requested services are not considered
medically reasonable and necessary in this case. Our physician reviewer found the enrollee suffers from
Lumbar Disc Degeneration, Depression, Asthma, Diabetes Mellitus, Hypertension, Thyroid Disease, Bipolar
Disorder, Anxiety and Chronic Pain. The enrollee's provider is requesting psychological testing to assess
chronic pain. The enrollee does not show any cognitive impairment documented. She does not have any mild or
questionable deficits of standard mental status testing or clinical interview. She does not have any CNS
disorder noted including cognitive dysfunction. Based on review the records provided, the enrollee does not
require psychological testing for the evaluation and treatment of chronic pain.
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 psychological testing and psychological testing evaluation services have not
been met. Therefore, we decided that the Plan does not have to pre-approve psychological testing (CPT 96136)
and psychological testing evaluation (CPT 96130) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided at the in-network benefit level by an out-of-network provider. 
 
You asked the Plan to pre-approve surgical services. You say that by choosing this provider you will pay the provider directly and you just want the Plan to cover the hospitalization charges at 100%. The Plan denied your request. The Plan says the denial of authorization for a cost-sharing waiver is correct, because you are responsible for 20% coinsurance when receiving covered services from an out-of-network provider. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for inpatient or outpatient hospital services.  
 
You may choose to receive services from this out-of-network provider. According to the Plan's benefits, you are responsible for 20% coinsurance for out-of-network inpatient hospital and outpatient hospital services. Hospital surgical services fall within the Inpatient Hospital Care or Outpatient Hospital Services benefit category, depending on your patient status during the hospital stay. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to preapprove the medical services to be provided at the in-network benefit level by an out-of-network provider.
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's health would continue to decline
without rehab. The Plan denied your request. The Plan says there is no indication that the enrollee requires an
intensive rehab program, or a rehab physician three times a week.
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 you are at maximum assist for transfers, moderate assist for bed mobility, and dependent for toileting,
upper body dressing, and lower body dressing. The complexity of your nursing, medical and rehabilitation
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You
may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not
support that you require this on an 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram.
You asked the Plan to pre-approve a transthoracic echocardiogram. You say that the requested transthoracic
echocardiogram is medically necessary. The Plan denied your request. The Plan says the requested
transthoracic echocardiogram is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a transthoracic echocardiogram. Our
reviewer says that the requested transthoracic echocardiogram is not medically necessary. Our physician
reviewer found the enrollee is with a history of paroxysmal atrial fibrillation, hypertension and
gastroesophageal reflux. An echocardiogram 08/2018 reported normal left ventricular ejection fraction (55%)
and mild LV hypertrophy. A nuclear stress test 01/08/2019 is reported to be normal. A clinic note dated
06/05/2020 documents no cardiac symptoms, a normal cardiac physical exam, and no change on
electrocardiography.
Based on the records the enrollee has no documented change in clinical cardiac status and an echocardiogram
less than 2 years ago with no significant valve disease and normal left ventricular ejection fraction. In this
circumstance the records do not support the medical necessity for a repeat echocardiogram. Current guidelines
also do not support the medical necessity for a repeat echocardiogram. Coverage criteria at not met since the
test exceeds the enrollee's medical needs 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 a transthoracic echocardiogram have not been met. Therefore, we decided that
the Plan does not have to pre-approve a transthoracic echocardiogram.
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 is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
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 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 (ex. SNF/SAR, outpatient rehabilitation, HHS, LTC). 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.