Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that 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 was admitted to the current acute care hospital for coronary artery bypass graft (CABG) and aortic valve replacement. The course was complicated by respiratory failure and difficulty weaning from ventilation support, pericardial tamponade requiring surgical chest exploration and evacuation, and hemodynamic instability requiring dobutamine. The WBC count has normalized and now he is off antibiotics. He requires hemodialysis, wound care, telemetry, physical therapy, and oxygen supplementation via tracheostomy. Based on the documentation provided, the enrollee appears to be stabilizing, however, he requires additional acute care services for the short term. The enrollee does not require services at the proposed LTACH that are not available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Completion of acute care services can be performed at the current facility and he can be transferred to a lower level of care when able. 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 a referral for a small bowel liver transplant with an out-of-
network provider.
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 provider must show medical need for why this needs to be done at a nonparticipating
facility.
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 for a small bowel liver transplant with an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50-mile one-way limit for routine transportation.
You asked the Plan to pre-approve an exception to the 50-mile limit. The Plan denied your request. The Plan says the trip exceeds 50 miles.
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 routine transportation up to 50 miles one way. Your request exceeds the allowed mileage for routine transportation. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50-mile one-way limit for routine transportation.
Appeal type: Drugs
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 SNF services. You say that SNF admission is not medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria 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 based on the medical records provided, 
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 skilled nursing needs. 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 also do 
not require skilled nursing or skilled therapy services daily. 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.
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. 
 
You asked the Plan to pre-approve PET scan. You say that the enrollee is declining rapidly and needs this test. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee does not meet the criteria for the requested PET scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found it 
should be noted that the enrollee is not being evaluated for an oncological purpose. A PET scan or computed 
tomography (CT) scan of the brain is considered medically reasonable and necessary in enrollees with a recent 
diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for 
both Alzheimer's Disease and Frontotemporal Dementia (FTD). The records do not support that the enrollee 
meets these criteria. Therefore, this test is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to a LTACH is needed for 
services that are not available at the current acute hospital. The Plan denied your request. The Plan says you do 
not have clinical conditions that cannot be appropriately treated in the current 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 you do not require any services in the proposed LTACH that are not already available 
in the current setting. Our reviewer found that there are no services at the proposed LTACH that you require 
that are not already available and covered at the current facility. Our physician reviewer also found that the 
request for LTACH services will be considered not medically necessary at this time. You may be appropriate 
for discharge to a lower level of care at a later date. 
 
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 the LTACH services.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve repeat radioembolization/selective internal radiation therapy
(SIRT) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is considered medically necessary when the individual has had a previous
satisfactory response, but the disease is still liver dominant.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the case is complicated by the fact that she has already received radioembolization. However, she had a
response to this for her left sided radioembolization (one of the criteria used by the insurer) and has progression
on the right side, with disease dominant in the liver (another of the criteria used by the insurer). It is notable
that the NCCN guidelines state that liver directed therapies are preferred over systemic therapy, and that
sorafenib would be appropriate after residual or recurrent disease "not amenable to additional local therapies."
Thus, every effort to maintain tumor control using liver directed therapies is "appropriate for diagnosis or
treatment of the condition" and "consistent with standards of good medical practice in the United States."
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 therapy have been met. Therefore, we decided that the Plan has to preapprove
repeat radioembolization/selective internal radiation therapy (SIRT) for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee does not still require 24-hour care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The documentation shows that continued inpatient services beyond August 25, 2020, were requested for 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 continued services. Our physician reviewer found that active treatment was not taking place. The services were not reasonably expected or medically necessary to improve the enrollee's condition, or for the purpose of diagnosis. Based upon review the records, this enrollee does not meet the criteria for treatment beyond August 25, 2020, and could be treated in a lesser restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, while being cooperative and compliant, while not showing any acute threats to safety. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sinus endoscopy procedure with maxillary antrostomy and total ethmoidectomy with Stereotactic computer-assisted navigation.
You asked the Plan to pre-approve the sinus procedure. You say that this is medically indicated. The Plan denied your request. The Plan says there is no evidence of a failure of maximal medical therapy.
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 sinus procedure. Our reviewer says that the requested procedures are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was a male who was seen in June 2020 with symptoms of nasal obstruction, facial pressure, headache, anosmia, and post-nasal drip. His symptoms have been present for 5 years. He is currently on Zyrtec, and has previously tried Flonase and Nasonex. His physical exam showed edema in the nasal cavity, clear rhinorrhea, turbinate edema, and S-shaped septum. He was given oral Augmentin and prednisone. It is not documented that he has tried sinus rinses. Also, his CT scan did not show evidence of persistent sinus disease. There was minimal mucosal thickening in the ethmoid sinuses, but there was no mucosal thickening in the maxillary sinuses. The current standard of care states that surgical management is not indicated if the CT does not show evidence of sinus disease. Therefore, sinus surgery is not medically reasonable nor necessary 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 sinus procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a sinus endoscopy procedure with maxillary antrostomy and total ethmoidectomy with Stereotactic computer-assisted navigation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0677). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the 
requested PCD. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliance (E0677).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee requires additional acute care services, however based on the clinical course and recent changes it is not likely to take more than 24 days. The enrollee does not require any services in the proposed LTACH that are not already available in the current acute care setting. The enrollee may be appropriate for discharge to a lower level of care soon. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the 
abdomen (74185). 
 
You asked the Plan to pre-approve the MRA of the abdomen. You say that the MRA is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs 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 MRA of the abdomen. Our reviewer 
says that the MRA is not medically necessary. Our physician reviewer found MRA  
 
 
 
 
of the abdomen typically are used to evaluate the vascular tree. In this case it's unclear based on the provided 
records why MRA of the abdomen is preferred over Computed Tomography with Contrast for the evaluation of 
a liver lesion. 
 
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 MRA of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the abdomen (74185).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a tracheostomy scar revision. 
 
You asked the Plan to pre-approve these services. You say that the scar pulls at your neck muscle. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you had a 
thyroid lobectomy on October 3, 2019. It appears you have a scar adhesion that is continuous from the skin 
surface through the subcutaneous layer, muscle layer, and thyroid cartilage. This will cause a swallowing 
deformity and tethering while swallowing. This is not a simple scar revision. You clearly have discomfort in 
your swallowing function and it is not a simple cosmetic issue. The requested procedure is reasonable and 
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 been met. Therefore, we decided that the Plan has to pre-
approve a tracheostomy scar revision.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay was 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a problem focused limited re-evaluation. 
 
You asked the Plan to pre-approve the re-evaluation. The Plan denied your request. The Plan says this service 
is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Plan only provides coverage for one emergency limited oral 
evaluation every 6 months. Problem focused limited re-evaluation is not listed as a covered benefit. Therefore, 
we decided that the Plan does not have to pre-approve a problem focused limited re-evaluation.