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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, skin care, and daily therapy can be provided at a SNF (or home with home health
services). In this case, you are mostly standby assist for functional transfers and activities of daily living
(ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a
reasonable, and predicted period. An IRF intensity is not warranted.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee no longer requires the skills of a licensed therapist, and can be
transitioned to a home exercise program.
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 enrollee has had extensive prior therapy and his deficits are
not so complex or indicate that he 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 enrollee has had training 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 additional physical therapy visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an acute IRF admission is medically necessary for
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of
an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do
not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled
nursing facility level of care. Ongoing pain medication and other medication management, wound/skin care,
and daily therapy can be provided at a skilled nursing facility. In this case, the enrollee requires minimal
assistance for functional transfers and mobility, and maximal assistance for activities of daily living. A less
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and
predicted period of time. The intensity of an IRF admission is not warranted.
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 an 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 transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH
are not 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 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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery to place a graft in the jawbone for the
enrollee.
You asked the Plan to pre-approve the surgery. You say that this is needed in order to facilitate sufficient bone
volume for future denture retention. The Plan denied your request. The Plan says primary dental services in
connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting
the teeth are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve oral surgery to place a
graft in the jawbone 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) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says any assistance that the enrollee needs may be provided by non-skilled personnel.
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 there are no identifiable skilled nursing
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for 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) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home-delivered meal services.
You asked the Plan to pre-approve the home meal delivery service. You say that you need these meals due to
your limited mobility. You need good nutrition in order to get well as soon as possible and feel that the Plan
should assist in paying for this service. The Plan denied your request. The Plan says Medicare does not cover
this type of meal delivery service.
The Plan must follow Medicare rules. Medicare rules say that custodial care, such as preparation and delivery
of meals, is not covered.
Although this service may be helpful for you, neither Medicare nor the Plan provides coverage for this service.
Therefore, we decided that the Plan does not have to pre-approve home-delivered meal services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary for the
enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met.
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 there are no identifiable skilled nursing service needs. The medical records do not show the
enrollee requires skilled nursing or skilled therapy services daily. The enrollee's condition does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Medicare coverage criteria for SNF services are not 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 SNF services have
not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF)
services for the enrollee.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare criteria for IRF care 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 preapprove
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 based on the medical records, the
complexity of the nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with
an interdisciplinary approach to rehabilitation care. The current medical status does not currently require
intensive physician and nursing oversight only in an IRF. The documentation does not support that your
endurance level can tolerate 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health aide services.
You asked the Plan to pre-approve the additional home health aide services. The Plan denied your request. The Plan says the additional hours would exceed the Medicare benefit.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. The file shows that 18 hours of home health aide services were requested. The Plan has agreed to pre-approve 12 hours, which would bring the home health services to 35 hours per week. We looked at the file, and Medicare rules. Home health aide services are covered as long as they are furnished (combined) less than 8 hours each day and 35 or fewer hours per week. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF
admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do
not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled
nursing facility level of care. Ongoing pain medication and other medication management, wound care, and
daily therapy can be provided at a skilled nursing facility. In this case, the enrollee is mostly moderate to
maximal assistance for functional transfers and activities of daily living. It is not clear the enrollee would be
able to fully benefit and/or participate in an IRF level of care. A less intensive, longer duration of therapy may
be more 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve an 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 inpatient hospital admission.
You asked the Plan to pre-approve inpatient admission. The Plan denied your request. The Plan says the
admission 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 inpatient admission. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that the enrollee is an 82-year-old female who presented to the ED with nausea and abdominal
pain and no bowel movement for several days. Vitals included low blood pressure of 86/49. CT abdomen
showed moderate stool. She was treated with stool softeners and IV fluids for diagnosed constipation and was
monitored. Vitals improved with treatment. Admission status was requested. Just prior to admission, according
to the notes provided, the enrollee appeared to be stable with normal blood pressure, responding to IV fluids
and the bowel regimen. Although additional investigation was warranted a GI workup, the CT scan and blood
testing did not reveal an acute process which warranted acute care services beyond an observation care level.
Therefore, this request for admission 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 inpatient admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve inpatient hospital admission.
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 records provided support the need for
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The
Plan say that the services needed can be provided in another setting.
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 ongoing care needs include oxygen supplementation, hemodialysis, surveillance
laboratory studies, wound care, 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.
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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not
support that her functional level requires 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you really need rehab. The Plan denied your request.
The Plan says the services are 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
requested IRF care is not medically necessary. Our physician reviewer found the submitted records show that
you were admitted to the hospital on June 19, 2020 after a fall, resulting in a neck spine injury. You were
treated surgically in the hospital and are working with physical and occupational therapy. You need minimum
to moderate assistance with transfers and activities of daily living. You are medically stable with no complex
needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You
may benefit from further therapy but do not require an intensive therapy program 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.