Persius/hicric huggingface dataset:
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 has had decline in the SNF and a 7-10 
day program in an IRF would be best to allow him to address his ongoing issues. The Plan denied your request. 
The Plan says the enrollee has no complex medical needs and aggressive three hours of daily therapy is not 
likely to reverse his long term mobility issues. 
 
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 underwent hip replacement on 8/18/20 and was discharged to a SNF. 
During the SNF stay, he had increased pain, swelling, acute kidney injury, and generally declining function. At 
this time, he appears hemodynamically stable with no fever or leukocytosis and is non-toxic. Functionally, he 
requires minimal to moderate assist for care.  
 
Records do not indicate that there are significant, or complex medical/nursing issues that require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's functional level 
would benefit from a less intensive, longer duration of therapy which will allow for measurable gains to be 
attained within a reasonable and predictable period. 
 
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 echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (CPT Code 93306). 
 
You asked the Plan to pre-approve the service. You say that the patient had original echo on March 9, 2020 but 
then had a bypass on June 11, 2020. You state the patient now needs a follow up echo after the bypass in order 
to start cardiac rehab. The Plan denied your request. The Plan says follow up imaging is only supported once 
per year. The Plan states the records do not describe this imaging time frame. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer 
found based on the records provided the patient had and echocardiogram March 9, 2020 followed by a CABG 
surgery June 11, 2020 with no documented cardiac complications and no abnormalities at the post-operative 
visit, September 1, 2020.  In this circumstance of a stable patient with no documented interval adverse cardiac 
events, no cardiac symptoms and no cardiac physical exam abnormalities medical necessity for a repeat 
echocardiogram < 1 year from the prior exam is not supported by the records provided. Current guidelines also 
do not consider repeat echocardiography appropriate in this circumstance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-
mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow 
Doppler echocardiography (CPT Code 93306).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for physical 
therapy 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee must receive care from a participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider for physical therapy
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery 
pressure monitoring system. 
 
You asked the Plan to pre-approve the CardioMEMS system. You say that this device will help with better 
management of the enrollee's heart failure. The Plan denied your request. The Plan says this is not proven 
superior to standard treatments in preventing hospitalizations based on current 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 CardioMEMS system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found therapy change based on data obtained from a CardioMEMS device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. 
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery pressure monitoring 
system.
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) 
for the enrollee. 
 
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 care can be provided in the current inpatient hospital. 
 
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 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. In this case, ongoing care needs include respiratory support with ventilator management, 
frequent suctioning, and  tracheosotmy care, intravenous antibiotics, surveillance laboratory studies, skin 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's needs are custodial and not skilled. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex 
wound care or other ongoing SNF level SN need. Your functional level does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee is with a past medical history of peptic ulcer disease, Barrett's esophagus, hypertension and diabetes 
who presented to the acute hospital in July 2020 with nausea, vomiting and abdominal pain. He was transferred 
to a second hospital on 08/11/2020. He was treated in the hospital for gastric outlet obstruction and has 
undergone multiple complicated surgical procedures. He has suffered an esophageal perforation, sepsis, acute 
kidney injury, deep vein thrombosis and Clostridium Difficile colitis. He has a Dobhoff feeding tube and is 
taking nothing by mouth due to aspiration on barium swallow evaluation. He had been intubated and supported 
with mechanical ventilation for respiratory failure and pneumonia but he is now extubated and has improved. 
He is weak and deconditioned and is working with physical and occupational therapy. He has not been able to 
get out of bed and is total assist for transfers and activities of daily living. 
 
The short-term acute care hospital can provide for all the enrollee's present inpatient care needs and the 
enrollee is receiving an appropriate level of care in the present setting. Continued care in the short-term acute 
care hospital is appropriate until the enrollee is stable to transfer to 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 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: 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. You say that these service are medically necessary. The Plan 
denied your request. The Plan says that your current care needs are custodial. 
 
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.
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 to allow for 
increased endurance and reconditioning. The Plan denied your request. The Plan says the enrollee has no 
complex medical conditions and her needs can be met with a less 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 58-year-old female with a past medical history of diabetes and 
peripheral vascular disease who presented to the acute hospital on 09/03/2020 with a non-healing infected 
wound on the right foot. She was treated in the hospital with antibiotics and required amputation of the right 
lower extremity below the knee. The surgery and her post-operative course were uncomplicated. She is 
unsteady and is working with physical and occupational therapy. She is walking 40 feet with a rolling walker 
with minimal assistance and is minimal assist for transfers and activities of daily living. She is medically stable. 
Transfer to an acute inpatient rehabilitation facility is requested. 
 
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical 
therapy and occupational therapy services but based on the medical records provided the patient does 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-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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found 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. In this case, ongoing 
care needs include respiratory support with BiPAP and oxygen supplementation, thoracentesis as indicated, 
intravenous antibiotics, surveillance laboratory studies, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission 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 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on September 8, 2020 with probable pneumonia. She has been walking with contact guard assistance and a two 
wheeled walker. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled 
therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure formula. 
 
You asked the Plan to pre-approve Ensure. You say that the enrollee needs Ensure for moderate calorie 
malnutrition. The Plan denied your request. The Plan says enteral nutrition is non-covered when it is taken 
orally as a drink. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. These items are not covered by 
Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pre-approve Ensure 
formula.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health skilled nursing visits. 
 
You asked the Plan to pre-approve the additional skilled nursing home visits. You say that you believe that you 
need to continue to receive your home health care services. The Plan denied your request. The Plan says there 
is no documentation of ongoing medical management requiring skilled nursing oversight, there is no 
administration of IV antibiotics, no new PEG tube or colostomy management, and no documentation of 
ongoing medical management changes which would require care from a skilled nurse. 
 
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 additional skilled nursing home 
visits. Our reviewer says that the requested additional home skilled nursing services are not medically 
reasonable and necessary. Our physician reviewer found the enrollee is an 82-year-old man with Parkinson's 
disease, Acute combined systolic (congestive) and diastolic (congestive) heart failure, Chronic embolism and 
thrombosis of unspecified vein, and Chronic venous hypertension (idiopathic) with ulcer of unspecified lower 
extremity. The enrollee was treated for lower extremity cellulitis in June 2020. There are no unhealed pressure 
ulcers. The enrollee is not receiving parenteral injections or enteral feedings. Skilled nursing services are not 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or 
to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. 
The documentation does not support that the enrollee has skilled nursing 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 additional skilled nursing home visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued home health skilled nursing visits.