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 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 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 there is no evidence of medical or nursing needs for an IRF. The enrollee needs 
physical therapy (PT) and occupational therapy (OT) but not in an IRF. There is no evidence of medical issues 
that require monitoring by an inpatient rehab physician three times a week. The documentation does not 
support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary 
approach to rehab care. At the enrollee's current functional level with confusion, she will not make a significant 
functional recovery in a reasonable and predicted period of time 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: Favorable

 
We decided that the Plan has to pay for inpatient admission. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care is medically necessary. 
The Plan denied your request. The Plan says that inpatient coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when determined to 
be 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 pay for acute inpatient 
hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met 
in this case. Our physician reviewer found inpatient admission it is medically appropriate in order to have a full 
evaluation and assessment of the etiology of recent altered mental status that has been worsening. Despite 
normal CT and MRI scans of the brain, there has been no further investigations demonstrated as to the etiology 
of the altered mental status. Medicare coverage criteria for inpatient care are met. We looked at this physician's 
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient 
admission.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the system is indicated for heart failure 
in enrollee's who have been hospitalized. The Plan denied your request. The Plan says this service is considered 
experimental and not generally accepted for the proposed use. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of coronary artery disease, hypertension, COPD, hyperlipidemia, 
reflux, and NYSHA Class III congestive heart failure with mildly reduced LV ejection fraction requiring 
hospitalization. In this circumstance 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.  
Concerns have been raised about potential bias in this trial calling into question the results. 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. Therefore, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are generally medically stable with Parkinson's disease at home with decline in 
function. There is no evidence of medical or nursing needs for an IRF. You need physical therapy (PT) and 
occupational therapy (OT) but not in an IRF. There is no evidence of medical issues that require monitoring by 
an inpatient rehab physician three times a week. The documentation does not support that there is a need for an 
intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. IRF admission is 
not medically necessary for you, and also does not meet the CMS coverage criteria due to lack of medical 
complexity. 
 
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 REBLOZYL (J0896). 
 
You asked the Plan to pre-approve REBLOZYL. 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 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 REBLOZYL. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found review of the compendia support the 
use of REBLOZYL for the treatment of myelodysplastic syndrome (MDS) with ring sideroblasts and 
thrombocytosis. The submitted pathology reports do not support the presence of ring sideroblasts. Without this, 
the compendia does not support the treatment and medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of REBLOZYL have not been met. Therefore, we decided that the Plan does not 
have to pre-approve REBLOZYL (J0896).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation of a wireless pulmonary 
artery pressure sensor. 
 
You asked the Plan to pre-approve a transcatheter implantation of a wireless pulmonary artery pressure sensor. 
You say that the requested procedure has been proven to be effective and safe. You say that the records 
provided support the medical necessity of the requested procedure. The Plan denied your request. The Plan 
says the requested procedure 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 a transcatheter implantation of a 
wireless pulmonary artery pressure sensor. 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 
Class II-III chronic heart failure (CHF). At his last visit office visit documented, he was well compensated and 
tolerating guideline directed medical therapy which was being titrated further. He had admissions to the 
hospital for pulmonary embolus in November of 2019 and a urinary tract infection in January of 2020. There is 
no record of admission for CHF exacerbation this year. The enrollee was very well compensated on his July 
2020 office visit and tolerating his medical therapy for CHF. Although published data does suggest that 
CardioMEMS sensor can be useful in decreasing repeated admissions for congestive failure in patients with 
severe CHF, the enrollee has been stable, well compensated on exam, with an excellent response to medical 
therapy and with no recent hospital admissions for CHF. Therefore, based on current data and practice, 
continuous monitoring with an implantable CardioMEMS device pressure sensor device does not appear 
medically necessary and reasonable at this point in the enrollee's clinical course. 
 
 
 
 
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 transcatheter implantation of a wireless pulmonary artery pressure sensor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter implantation of 
a wireless pulmonary artery pressure sensor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you live alone and have no family and are not doing well.The Plan denied your request. The Plan says you have exhausted your 2020 transportation benefit as of September 28, 2020.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of fifty (50) one-way tripsper year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does nothave to pre-approveadditional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor did not submit any documentation showing that injury or surgery has 
occurred. 
 
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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with complaints of right knee pain. Functional limitations are reported in 
ambulatory tolerance. Clinical exam findings are consistent with reported imaging evidence of bone-on-bone 
lateral compartment osteoarthritis. She has failed to achieve adequate relief with activity modification, heat/ice, 
and injections. She did not want to have surgery at this time. Under consideration is a request for a right knee 
orthosis (L1843). Medicare coverage criteria have not been met. There is no evidence in the medical records of 
a recent injury or a surgical procedure on the knee. Knee instability has not been clearly documented. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis.
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 stay is medically necessary.The Plan denied your request. The Plan says the stay is 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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen (15) 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-approveacute 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to 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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for pancytopenia and renal dysfunction. The 
enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
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 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 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 location. Continued care at the current facility is recommended. Therefore, this request for LTACH 
services will be considered not medically necessary at this time. Transfer to a lower level of care may be 
considered soon based on the clinical improvement thus far. 
 
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 long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute 
care facility. 
 
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. The patient 
appears to be improving and requires additional short term acute care services, but is not likely to require more 
than 25 days. The patient does not require services at the LTACH that are not already being provided in the 
current setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH 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 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation mileage.You asked the Plan to pre-approveadditional routine transportation mileage. You say that you have not been able to walkfor five (5) months and that you are in a lot of pain. You state you need the transportation to get to and from doctor appointments to try and figure outwhy you are in pain.The Plan denied your request. The Plan says you have met the Plan limits whichhave been set in the subscriber agreement.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. You are requesting an additional 125 miles fora total of 175 miles. Your benefit only allows 50 miles. You have exceeded your benefit limit. This request is not covered by your health plan.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation mileage.
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 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 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 review has determined that the enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are currently receiving care. There are no services at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.