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 you would be back to normal sooner in an IRF than at a lower level of care. The Plan denied your request. The Plan says IRF admission 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. There is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says the medical records do not show that the enrollee meets
the guidelines for coverage of SNF care. The plan says that the enrollee's needs can be met in the current
hospital setting.
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 SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not
reveal that the enrollee's orthostatic hypotension has improved to the point that she can effectively participate
in a SNF therapy program. The enrollee does not require skilled therapy services with the specialized skill,
knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary
and reasonable treatment at a SNF level at this time, given her medical progress notes that indicate persistent
hypotension. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of
these services) on a "daily basis" in a SNF. As a practical matter the enrollee does not require the necessary
services on an inpatient basis, in a skilled nursing facility setting 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sacroplasty (0200T).
You asked the Plan to pre-approve Sacroplasty (0200T). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the denial of Sacroplasty (0200T) is consistent with the Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. In this case, Sacroplasty (0200T) is considered a Category III code and is not covered by Medicare or the plan. Therefore, we decided that the Plan does not have to pre-approve Sacroplasty (0200T).
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 need to build strength and have help with meals, and the hospital will not discharge you without you going to an IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 in an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physical evaluation. Your needs can be met at a lower level of care such as Skilled Nursing Facility (SNF). 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: 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 SNF admission. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (CPT E0118).
You asked the Plan to pre-approve the knee scooter. You say that the plan advised you on February 3rd and 4th of 2020, that a knee scooter would definitely be covered. You say that you will require the use of this durable medical device to assist in your recovery and to aid in your mobility during the 6 week rehabilitation period. The Plan denied your request. The Plan says the item in dispute is a non-covered device because of a lack of published clinical literature demonstrating safety and effectiveness.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare has determined that platform crutches will be denied as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (CPT E0118).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve the Synvisc-One. You say that Synvisc-One is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the record does not indicate medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the member has not tried and failed a trial of Monovisc and Orthovisc. Our physician reviewer found without support of the documentation, Synvisc-One is not approved as step therapy criteria is 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 the Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.
You asked the Plan to pre-approve the Supartz FX. You say that Supartz FX is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the submitted documentation does not support the medical necessity of a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Supartz FX. Our reviewer says that the member has not tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found Supartz FX is not approved as step therapy criteria have not been 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 the Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member's needs may be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission.. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not require the necessary services on an inpatient basis in an SNF 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 SNF admission. have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a brain PET is covered when specific criteria are met. 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 the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unspecified dystonia. He has progressive weakness and muscle atrophy that is severely affecting his gait, as well as causing significant pain. Multiple EMGs and lab work have been completed without a clear diagnosis for symptoms. There is no documentation of cognitive decline. The enrollee does not meet the criteria for coverage of a brain PET and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest.
You asked the Plan to pre-approve the scan. You say that this is medically necessary, as PSA levels have continually increased with likely indicates further metastasis. The Plan denied your request. The Plan says that this is not reasonable and necessary under Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the concern for metastatic disease due to the prostate cancer is a real possibility. The requested CT of the chest is important not only for detailed viewing of the skeleton in light of a known single boney metastatic lesion in the right ilium on bone scan of 5/16/19 but also rarely prostate cancer may metastasize to hilar/mediastinal lymph nodes and occasionally the lungs. CT of the chest is the most reliable test for such 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest.
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: 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 need rehab and dialysis. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the records show that your ongoing care needs include surveillance laboratory studies, dialysis, care for your ileostomy, and therapy. You do not require any services at the LTACH that are not available at the acute care hospital where you are 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 you 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs Medicare guidelines for coverage of IRF care and has the medical necessity to warrant this level of care. You say that the clinical information provided supports the requested IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The plan says that the enrollee can safely receive the services needed 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 the 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, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate to maximum assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would be able to fully benefit from and/or participate in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of lower or sacral facet joint, using imaging guidance.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no new clinical documentation submitted to support the medical necessity of this procedure.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no reason to repeat diagnostic blocks after RFA when the prior procedure produced long lasting relief. Unbundling of the fluoroscopic code is not allowed. You have no indication for monitored anesthesia care. The requested procedures are not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an injection of lower or sacral facet joint, using imaging guidance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home modifications and a walk-in tub.
You asked the Plan to pre-approve home modifications and a walk-in tub. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve home modifications and a walk-in tub.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after February 9, 2020.
You asked the Plan to pre-approve continued SNF care. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after February 9, 2020 is correct.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after February 9, 2020.