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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's physical medicine and rehabilitation physician believes she would benefit from an IRF stay. You say that the enrollee needs rehabilitation at the acute level and needs medical managementto regain maximum function.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 could receive care 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 enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or acute rehab nursing care. Our physician reviewer found that, while the enrollee may benefit from continuing physical and occupational therapy, there is no evidence of a 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-approveacute 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 enrollee's needs can be safely and better managed in a less restrictive setting. The plan says that the enrollee is medically stable.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 continues to receive wound care. Our physician reviewer found that the enrollee has pain which needs to be assessed and treated. Our physician reviewer found that the enrollee requires oversight of his medical conditions and medication management. Our physician reviewer found that the enrollee is at risk for secondary complications of immobility, such as pressure ulcers and contractures. Our physician reviewer found that the enrollee has not returned to his prior level of function. Our physician reviewer found that the enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Our physician reviewer found that, while the enrollee does require skilled nursing and skilled therapy services, as described above, he does not require them on a daily basis. Our physician reviewer found that, based on the enrollee's progress to date, the expectation of achieving gains that would impact the burden of care ate discharge with daily skilled services is not expected. 
Our physician reviewer found that the enrollee appears to have reached a functional plateau consistent with his current orthopedic precautions and co-morbid medical conditions. Our physician reviewer found that, when the enrollee's orthopedic precautions can be advanced, a reassessment for the potential of measurable gains within a reasonable and predictable period of time would be expected. Our physician reviewer found that the enrollee is receiving care that can be provided by his non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. Our physician reviewer found that the enrollee's condition would not be expected to deteriorate with services provided on a less than daily basis.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Verio test strips for the enrollee.
You asked the Plan to pre-approve the test strips. You say that the enrollee wants these test strips because they go with a meter the enrollee got from his nutritionist. The Plan denied your request. The Plan says that the enrollee has not tried and failed use of a preferred meter.
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. We looked at the file and Medicare rules. The file does not include any medical reason documenting why the enrollee requires this specific brand of test strips over the plan's preferred test strips. Without this, medical necessity cannot be established. Therefore, we decided that the Plan does not have to pre-approve One Touch Verio test strips for the enrollee.
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) .
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 there was not a safe and secure tracheostomy.
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 based on the provided medical records, the acute care hospital is able to provide all of the services that the enrollee requires. Based on the provided medical records, the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at the acute hospital level is appropriate until the enrollee is able to transfer to 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 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) .
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 medically necessary. The Plan
denied your request. The Plan says based on the documentation provided, your needs can be met at a lower
level of care. Therefore, coverage criteria for IRF care 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 medical records do not indicate that there are significant, or complex
medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing
pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In
this case, you are mostly minimal standby assist for functional transfers and activities of daily living (ADLs)
and a less intensive, longer duration of therapy will allow for measurable gains to be attained 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: 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 requires IRF care for rehabilitation. The Plan denied your request. The Plan says the enrollee's condition is such that he will not likely be able to participate in three hours of daily therapy.
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 readmitted on 12/14 due to recurrent incisional hernia after partial small bowel resection on 12/10. The enrollee has had poor oral intake and is malnourished and requires IV antibiotics. The recent records indicate the enrollee is afebrile and non-toxic. Three abdominal wounds are noted, and VAC care is being implemented. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician supervision in the acute hospital setting. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at an alternate level of care. In this case, the enrollee is mostly moderate to maximal assist for functional transfers and ADLs and a less intensive, longer duration of therapy will allow for measurable gains to be attained 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for use in spinal fusion surgery.
You asked the Plan to pre-approve the bone marrow aspirate. You say that this should be approved. The Plan denied your request. The Plan says the use of bone marrow aspirate is not proven effective so it cannot be covered.
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 bone marrow aspirate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee is indicated for direct lumbar interbody fusion T12-L2, and posterior spinal fusion T10 to the pelvis. Under consideration is a request for bone marrow aspirate. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspirate would not be considered 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 the bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for use in spinal fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says a home oxygen system was previously provided.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. 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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have a home oxygen concentrator and compressed air tanks for mobility within the home. You are requesting the portable oxygen concentrator for use outside the home. Medicare only covers portable oxygen systems for mobility within the home. The portable tanks meet that need. A portable concentrator for use outside the home is considered a convenience, which is not covered by Medicare. It is therefore considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical oncology services to be provided by out of network (OON) provider.You asked the Plan to pre-approve the OON medical oncology services. You say that the in-network providers being offered for this care have bad reviews and one treated another family member who was dissatisfied. You believe that the enrollee should be allowed to receive all care from OON providers.The Plan denied your request. The Plan says surgical oncology services were approved as this provider does contract with the Plan, though the Plan does not contract with the provider. There are network medical oncologists who can provide the care needed. As such, there is no need to approve OON care.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 pre-approved care.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 the medical oncology services to be provided by out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine non-ambulance transportation to dialysis treatments.You asked the Plan to pre-approve the routine transportation. You say that you need to go to dialysis three times per week and need to have transportation provided.The Plan denied your request. The Plan says your plan does not cover routine transportation to dialysis. Medicare only covers ambulance transportation.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 a one-way trip to the home after discharge from the emergency room or transportation to a physician related to continued home-care services. Routine transportation to scheduled dialysis visits are not among the types of transportation covered by your plan.Therefore, we decided that the Plan does not have to pre-approve routine non-ambulance transportation to dialysis treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.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 the services are not covered.The Plan must follow Medicare rules. The rules say that Cranial Nerve (Hypoglossal) Stimulation for the treatment of Obstructive Sleep Apnea (Category III Codes 0466T, 0467T, 0468T) has been determined to be not reasonable and necessary.The services at issue are hypoglossal nerve stimulation described by code 0466T. These services are denied by Medicare as not medically necessary.Therefore, we decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that your care can be provided at home/outpatient setting or long-term care facility.
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 that your condition does not meet Medicare criteria for continued SNF services. 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 continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says based on the documentation provided, medical necessity for IRF care has
not been established.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or
nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT)
and occupational therapy (OT) but the enrollee's functional level does not require this on an intensive
rehabilitation facility therapy program level 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve corneal topography (92025). You asked the Plan to pre-approve corneal topography. You say that the service is necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.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 corneal topography. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found in this case it is noted that you have had a diagnosis of bilateral keratoconus, have had a corneal graft, and have had evidence of rejection. The documentation in the case file supports that the computerized corneal topography is 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 corneal topography have been met.Therefore, we decided that the Plan has to pre-approve corneal topography (92025).