Persius/hicric huggingface dataset:
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 is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 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 evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's 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. The enrollee was noted to be appropriate for inpatient behavioral health due to the enrollee's confusion and agitation. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a 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 care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four further home health occupational therapy (OT) visits.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says five visits are approved but four further are not medically necessary.
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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a recent hospitalization for pneumonia and sepsis. She has had 16 approved OT visits. By the dates in question, she needs a set up or clean up assist level for transfers and varied assist with activities of daily living. The records do not support that four additional OT visits are reasonable and medically necessary. Further skilled OT visits are not required to effectively provide treatment, care, and/or services which are necessary for the enrollee. 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 four further home health occupational therapy (OT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve the SI joint injection. You say that it is felt that this treatment can reduce the enrollee's pain. The Plan denied your request. The Plan says the documentation does not support that this treatment is medically necessary at this time.
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 SI joint injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no imaging of the SI joint. The physical exam does not include SI joint provocative maneuvers or documentation of physical therapy for the SI joint and hip. 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 SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted following an asthma exacerbation and atrial fibrillation. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), with independent controls of this function (K0108), and a manual swingaway mounted hardware (E1028).
You asked the Plan to pre-approve the requested items/accessories. You say that these items are needed. The Plan denied your request. The Plan says the wheelchair tray E0950 was approved. However, the remaining codes are denied as they are not medically necessary or are included in other items.
The Plan must follow Medicare rules. Medicare rules say that power seat elevations systems are not covered. In addition, the use of code E1028 cannot be used to describe hardware associated with the tray E0950. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300), with independent controls of this function (K0108), and a manual swingaway mounted hardware (E1028).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 33 additional home health skilled nursing visits. You asked the Plan to pre-approve33 additional home health skilled nursing visits. You say that the additional skilled nursing home health visits are medically necessary.The Plan denied your request. The Plan says the criteria for additional home health skilled nursing visits have not been met.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 pre-approve 33 additional home health skilled nursing visits. Our reviewer says that the additional home health skilled nursing visits are not medically necessary and reasonable. Our physician reviewer found that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration beyond the approved visits. Currently the documentation does not reveal that ongoing wound care is complex and requires skilled nursing care for the remaining requested visits. You have had extensive prior wound care and should be educated in signs and symptoms of infection. Finally, you have a vascular surgery follow up on July 15, 2021,and can be re-evaluated at that time by your physician whether there are changes in the treatment 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 33 additional home health skilled nursing visits have not been met.Therefore, we decided that the Plan does not have to pre-approve33 additional home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; whole body (CPT code 78816), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that this provider is out-of-network because there is not PET imaging center within thirty (30) miles. The Plan denied your request. The Plan says there are in-network providers that can provide this service.
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 PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; whole body (CPT code 78816), 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 you disagree with the denial. 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 in the Medicare rules section. 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 enrollee was admitted for acute on chronic kidney disease associated with staghorn calculus. He has a sacral pressure ulcer. He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 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 disagree with the denial.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 in the Medicare rules section.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 enrollee was admitted to the hospital on June 14, 2021 with left lower extremity pain and numbness. She underwent surgery on June 23, 2021. The occupational therapy evaluation on June 24, 2021 states she needs minimal assist for bed mobility and transfers and walking two feet. She needs maximal assist for seated lower body dressing. She does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-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 the continuation of inpatient mental health care from April 21, 2021 and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care from April 21, 2021 and forward. You say that the requested continuation of inpatient mental health care from April 21, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the requested continuation of inpatient mental health care from April 21, 2021 and forward is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 continuation of inpatient mental health care from April 21, 2021 and forward. Our reviewer says that the requested continuation of inpatient mental health care from April 21, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. This enrollee was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of April 21, 2021 and forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any 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 the continuation of inpatient mental health care from April 21, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from April 21, 2021 and forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Coflex interlaminar stabilization device.You asked the Plan to pre-approve the Coflex placement. You say that this is a medically necessary treatment at this time.The Plan denied your request. The Plan says spinal decompression has been approved butuse of this Coflex device remains experimental at this time.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 Coflex placement. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device remains experimental for use. High failure rates have been reported with similar devices. 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 Coflex placement have not been met.Therefore, we decided that the Plan does not have to pre-approve placement of the Coflex interlaminar stabilization device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an IRF therapy program. The Plan denied your request. The Plan says it does appear member would benefit from ongoing therapy to maximize rehab potential, but there is no evidence that the member cannot adequately recover in a less intensive setting such as SNF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 admitted to the hospital on 6/18/2021 after a fall causing multiple fractures. Surgical fixation was provided for the hip fracture. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower 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 pay for the chiropractic manipulation of the spine provided on February 8, 2021.
You asked the Plan to pay for the chiropractic manipulation. You say that you feel that this should be considered a medically necessary treatment and not maintenance. The Plan denied your request. The Plan says you were informed that this treatment was considered maintenance and would not be covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.
In this case, you were asked to sign a notice which informed you that the services were considered to be maintenance. This is not a covered service under Medicare. Based on this information, we decided that Medicare rules for coverage of the chiropractic manipulation have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulation of the spine provided on February 8, 2021.
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 want to go to a rehab facility in order to help walk again The Plan denied your request. The Plan says the record does not show that you meet guidelines for services in an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. You require physical and occupational therapy but there is no documented need for an
intensive rehabilitation program. Medically necessary services can be provided in a different level of care.
There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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.