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

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for acute on chronic respiratory failure and was treated for pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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 does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is
living at home receiving home health physical and occupational therapy services. The enrollee has persistent
weakness and difficulty with transfer. Medical conditions are stable. There are no medical needs requiring
inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the medical record documents a need for physical and occupational
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable
expectation that this 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy services (CPT Code
97168), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says based on the clinical information provided to the Plan, the enrollee had minor
improvement in arm strength and continue to have weakness and trouble with movement of their arm. The Plan
states the notes do not show the enrollee needs the ongoing skills of an occupational therapist since their
condition does not seem to be improving with 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 services. Our physician reviewer
found the medical record is reviewed in its entirety. The enrollee has been receiving occupational therapy
services since September of 2020 with minimal improvement in strength or function. The enrollee is not
expected to make measurable gains within a reasonable and predictable period of time or require skilled
therapy to prevent deterioration with mobility or ADLs. The enrollee does not require skilled therapy to
establish a safe and effective maintenance program. The enrollee received skilled occupational therapy services
with minimal improvement and does not require further occupational therapy services. The enrollee's needs are
custodial in nature and can be managed with a home exercise program. The enrollee or their caregiver should
be independent with a home exercise program. The additional therapy services are 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional occupational therapy services (CPT Code 97168), for the enrollee.
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 continued SNF care. You say that continued care is medically necessary. The Plan denied your request. The Plan says your needs could be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the rules are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, you required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. You did not require any skilled nursing or rehab services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time and did not require skilled therapy to prevent deterioration. You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you do not require any skilled services on an inpatient basis, at a SNF level of care. You received skilled care and improved. Your function had plateaued by February 24, 2021, and you do not require any further inpatient skilled rehab services. You function was at or near her prior level of function and you could be discharged to a lower level of care for further services as your needs are now custodial.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis procedures provided from January 27, 2020, to January 31, 2020.

You asked the Plan to pay for the dialysis procedures. You say that the services that were rendered are not in relation to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the dialysis procedures provided from January 27, 2020, to January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positioning cushion/ pillow (CPT Code E0190).

You asked the Plan to pre-approve the item. You say that due to the severity of the enrollee's diagnosis of
GERD/LP they have been choking when lying flat on the back or on the side. The Plan denied your request.
The Plan says a positioning cushion or pillow is a personal comfort item, and not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve positioning cushion/ pillow (CPT Code E0190).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2393), gingival irrigation (D4921 x 3), and the localized delivery of antimicrobial agents (D4381).

You asked the Plan to pay for the fillings, localized delivery of antimicrobial agents, and gingival irrigation. You say that you are unhappy and dissatisfied with the service that your dental office provides. You say that you were never informed of the treatment they claimed that was done by them. You say that you went for a basic routine yearly check up that you usually have. You say that you explicitly told them that you have no money to have any extra work done if it is not covered by your insurance. You also say that The Plan denied your request. The Plan says 1 filling per calendar year is covered. The Plan says that the frequency limit for this service has been exceeded. The Plan says that localized delivery of antimicrobial agents is not listed as a covered service. The Plan also says that Gingival irrigation is not listed as a covered service either.

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 frequency limit of 1 filling per calendar year has been exceeded. The record shows that the Plan paid for a filling. Additionally, localized delivery of antimicrobial agents and gingival irrigation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2393), gingival irrigation (D4921 x 3), and the localized delivery of antimicrobial agents (D4381).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq.

You asked the Plan to pre-approve Myrbetriq. You say that the enrollee has tried and failed VesiCare. The Plan denied your request. The Plan says Myrbetriq to be taken at home is not covered under the Part B benefit.

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 Myrbetriq.

Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 appear to be improving although additional short-term acute care services are warranted which can safely be administered at the current facility until able to discharge to a lower level of care. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer may be considered when treatment has completed. 

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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT Code C2624).

You asked the Plan to pre-approve the service. You say that you would like to measure and monitor the
enrollee's pulmonary artery pressure because the enrollee needs the device due to their worsening heart failure.
The Plan denied your request. The Plan says the service is considered experimental and investigational.

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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that in this circumstance, therapy change based on data obtained from a CardioMEMS device
has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared
to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare
coverage criteria are not met, since the device should still be considered experimental or investigational.

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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CardioMEMS device (CPT Code C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted for myocardial infarction and coronary artery bypass grafting. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your 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 pre-approve Facet Joint Radiofrequency Neurotomy Ablation (RFA) (CPT Code 64635).

You asked the Plan to pre-approve the services. You say that the service is medically necessary and beneficial to the enrollee. The Plan denied your request. The Plan says the requested repeat procedure is supported when documentation includes that prior procedure provided 50% or more improvement of pain and improved activities of daily living (ADLs) for at least 6 months. The Plan states the clinical information provided does not meet this criterion and, therefore, the requested procedure is not indicated at this time.

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 services. Our physician reviewer found the criteria for repeat RFA not met. There is no documentation of adequate pain relief and duration with previous injection therapy. The repeat RFA is not medically needed.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Facet Joint Radiofrequency Neurotomy Ablation (RFA) (CPT Code 64635).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted for a urinary tract infection, sepsis, deep vein thrombosis, pulmonary embolism, and gastrointestinal bleeding. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of femur fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the request is considered experimental and investigational.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure as there only a few published studies and the longer term effects are not published. Therefore, the request is considered not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.