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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 02/03/2020 for sepsis with septic shock due to pneumonia and gram negative bacteremia. Her hospitalization has been complicated by respiratory failure requiring intubation and mechanical ventilation for five days. Her respiratory status has improved and she is weaning off of 3L oxygen. Antibiotics changed tooral route. On 2/16/20, a physician note said that she was medically stable for discharge. Based on review of the available records, the enrollee, with debility from recent respiratory illness does not meet Medicare coverage criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physician three times a week or needs acute rehab nursing care. She may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program as she is unable to tolerate more than 25 minutes of therapies. IRF admission is 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 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 IRF is the best option for recovery. 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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on February 12, 2020 with a hip fracture and underwent surgical repair on February 13, 2020. The physical therapy note dated February 18, 2020 states you need assistance with sitting and standing up. You have no complex issues that require the intensity of services provided at an IRF. Specifically, the records do not support that you would be able to perform fifteen hours per week of rehabilitative services with 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is unstable and needs placement. 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 enrollee was admitted to the geriatric psychiatric unit of the LTACH on August 31, 2019. He is currently undergoing treatment at a LTACH. The enrollee is not shown to be in need of acute medical services. The LTACH services are 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 you do not require skilled nursing or therapy
services on a daily basis. You do 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 skilled nursing facility (SNF) care.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the member suffered a
mechanical fall, and was also with abrupt confusion preceding the fall. No syncope was reported. The member
was imaged and cervical spine was free of traumatic fracture. MRI revealed a right occipital ischemic infarct.
The member has a history of stroke and gastrointestinal (GI) bleed. Medications include statin therapy and
Namenda for cognitive dysfunction. The member is now neurologically and hemodynamically stable. The
member is minimum/moderate assist for mobility and activities of daily living per recent therapy notes
reviewed.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lower level of care. Ongoing pain medication and other medication management, skin care, and
daily therapy can be provided at a lower level of care. In this case, the member is mostly moderate/minimum
assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy can
allow this member to attain measurable gains within a predicted period.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with acute on chronic congestive heart failure. From a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a stand by assist to minimal assist level with bed mobility and transfers. He used a power wheelchair or scooter for ambulation prior to admission. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a skilled nursing facility (SNF) 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine Sulfate ER for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this drug is not covered under Medicare Part A or Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Morphine Sulfate ER for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome visits (99349) provided on May 24, 2019; June 12, 2019; July 30, 2019; August 28, 2019; and September 25, 2019.You asked the Plan to pay forhome visits. You say that you were not informed these services would not be covered.The Plan denied your request. The Plan says no skilled services were necessary or provided in these visits.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for home visits. Our reviewer says that the visits at issue were not medically necessary. Our physician reviewer found home health notes indicate you were receiving skilled nursing for a physical assessment each visit with an emphasis on diabetes and neuropathy. The notes indicate visits were primarily educational in nature. Vital signs and weights were monitored. Your wound care consisted of Betadine and Kerlix. Based on available records, you do not meet criteria for coverage of the requested home health nursing visits during the dates at issue. There were no complex skilled nursing needs. The records do not show that skilled nursing services were required to effectively provide treatment, care, or services which are 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 home visits have not been met.Therefore, we decided that the Plan does not have to pay forhome visits (99349) provided on May 24, 2019; June 12, 2019; July 30, 2019; August 28, 2019; and September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the requested continuation of SNF care does not meet criteria.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 todetermine if the Plan was correct in denying the request to pre-approve the continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with Parkinson'sdisease, spinal stenosis, cervicalgia, benign prostatic hyperplasia (BPH) and cervical laminectomy with decompression surgery and then admitted to the SNF. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He had routine foley catheter care. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By 1/30/20, the date of most recent notes, the enrollee was at a supervision level with functional mobility including gait to 300 feet. The enrollee required varying assist with activities of daily living from supervision to moderate assist. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.  The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 continuation of skilled nursing facility (SNF) care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) exercise device for use other than knee.
You asked the Plan to pre-approve the CPM. You say that having this DME would tremendously help with regaining full mobility of your shoulder. You say that you live alone and only have the physical therapy, which is becoming too costly to keep up with. The Plan denied your request. The Plan says the requested device does not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion (CPM) exercise device for use other than knee.
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 enrollee was medically stable with no evidence of need for supervision by a physician three times a week or needs acute rehab nursing care. They may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program as they are unable to tolerate more than 10 minutes of exercises. IRF admission is 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 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 8 additional outpatient physical therapy visits.You asked the Plan topre-approve8 additional outpatient physical therapy visits. You say that the enrollee is still experiencing substantial limitations in range of motion. You say that the enrollee's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is hindered. You also say that the enrollee's high levels of pain are impacting her ability to sleep.The Plan denied your request. The Plan says the enrollee does not meet criteria for continued outpatient physical therapy. The Plan also says that further management can continue with the prescribed Home Exercise Program (HEP).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 8 additional outpatient physical therapy 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 that the provided documentation does not reveal that the requested 8 therapy visits would be specific and effective for the enrollee's condition. The enrollee has been authorized for 4 sessions to transition to a home exercise program. The reviewer found that the deficits remaining do not require 8 supervised therapy visits. The enrollee can transition to an independent home exercise program with the already authorized therapy. The complexity of the enrollee's condition is not at a level of sophistication that the services required can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The ongoing skills of a therapist are not needed to treat the illness or injury and the patient can transition to an independent home exercise program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 8 additional outpatient physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve8 additional outpatient physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON office visit. You say that you have a lump in your throat and that you were diagnosed with cancer. You say that you were referred to an oncologist. You say that you have two friends who saw this provider and were provided with good results. The Plan denied your request. The Plan says there are in-network providers who are able to provide oncology consultation services.
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 an office visit to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSPECT Myocardial perfusion imaging (78452).You asked the Plan to pre-approvethe Myocardial perfusion imaging. You say that the test 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 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 Myocardial perfusion imaging. Our reviewer says that the requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has no history of cardiovascular disease or any cardiac related symptoms noted. The only active diagnosis listed for the SPECT study is hypertension. This is not a covered indication.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 Myocardial perfusion imaging have not been met.Therefore, we decided that the Plan does not have to pre-approveSPECT Myocardial perfusion imaging (78452).