Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 and F5 gene analysis. 
 
You asked the Plan to pre-approve F2 and F5 gene analysis. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare says that the F2 and F5 gene analysis is not medically 
necessary. Based on this information, we decided that Medicare rules for coverage of F2 and F5 gene analysis 
have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 and F5 gene analysis.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there was no documentation of the need for an intensive rehabilitation 
program requiring therapy at least 3 hours per day for 5 days per week, goals for measurable improvement, 
close physician involvement, skilled nursing care, physical therapy, occupational therapy, or 
orthotics/prosthetic training. 
 
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. 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 
enrollees care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered in the current setting. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer to a lower level of care may be considered at a later date if 
improvement and stability are achieved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include respiratory support with ventilator management, oxygen supplementation, telemetry, 
surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that 
the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where 
he is currently receiving care. There are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with osteomyelitis. 
The enrollee failed outpatient treatment and was admitted 7/30/2020 for management. Medications prescribed 
included IV Vancomycin and Meropenem. Hospital course was notable for management of renal insufficiency. 
Now, she is afebrile and frequently remains incontinent of bowel. She is moderate assist for activities of daily 
living and transfers. Wound care is ongoing. Renal parameters are now stable, with BUN 26, Cr. at 1.31.  
 
The enrollee remains moderate assist for care, and ongoing therapy, and wound care needs can  be provided at 
a lesser level of service. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat RFA. 
 
You asked the Plan to pre-approve the repeat RFA. You say that you would like reconsideration because this 
service is medically necessary to treat your lower back pain. The Plan denied your request. The Plan says you 
have not had the required duration of pain relief for the repeat RFA. 
 
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 repeat RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you did not receive 50% pain relief for 3 months from the last RFA. 
 
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 repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat RFA.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would be best served by care 
in the LTACH setting. The Plan denied your request. The Plan says with additional time in the current setting, 
clinical stability can be ensured such that an appropriate lower level of care can be determined. 
 
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include respiratory support including CPAP support and 
tracheostomy care, surveillance laboratory studies, hemodialysis, tube feedings,  and therapy services. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code S8423, 
S8429, A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings to treat 
lymphedema. The Plan denied your request. The Plan says this is not a covered condition for compression 
stockings. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code S8423, 
S8429, A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say 
that compression bandages and gradient compression wraps are covered only when they are used as dressings 
over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
S8423, S8429, A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted to the current acute care hospital with altered mental status and small bowel obstruction. 
She was treated with surgical intervention, however, the course was complicated by atrial fibrillation, 
pneumonia requiring antibiotics, and acute kidney injury requiring dialysis. She started receiving PEG tube 
feeds recently and is requiring oxygen and IV fluids for hypernatremia. She has recently had elevated WBC 
count and tachycardia. 
 
The enrollee in this case appears to be still requiring acute care services, however should not require more than 
an additional 25 days of acute care services based on the recent notes. The enrollee does not require any 
services at the LTACH that are not already available at the current setting. There are no services at the LTACH 
that the enrollee requires that are not already available and covered in the current setting. Therefore, this 
request for LTACH services will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that 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 based on the documentation provided, the enrollee does not require the intensity of 
services provided at an IRF.  Specifically, the enrollee is not shown to require, or to be able to perform, fifteen 
hours per week of rehabilitative services and regular physician evaluation. Medicare coverage criteria are not 
met. 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 for the enrollee.
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 SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, 
you do not require skilled nursing or skilled therapy services on a daily basis at an inpatient SNF level of care. 
Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: 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 SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continued SNF care. 
 
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 continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with 
pathologic femur fracture and was admitted to the SNF. From a nursing perspective, the enrollee received oral 
medications.  The enrollee had stable vital signs. She was treated for pain with effect.  Her lungs were clear. 
Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF.  
By the dates in question, the enrollee was at a stand by assist to contact guard assist level with functional 
mobility including gait to 119 feet with a rolling walker.  The enrollee required varying assist with activities of 
daily living. She remained toe-touch weight-bearing to her right lower extremity. 
 
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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injections for the knee. 
 
You asked the Plan to pre-approve the Synvisc injections. You say that the recent MRI shows that this 
treatment is needed. The Plan denied your request. The Plan says criteria for Synvisc treatment are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Synvisc injections. Our reviewer 
says that the documentation does not support that the criteria for this treatment are met. Our physician reviewer 
found the record does not include any knee x-rays showing arthritis. An MRI is not the appropriate test for this 
condition. Without an x-ray, the diagnosis of degenerative joint disease is not confirmed. 
 
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 Synvisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc injections for the knee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the 
enrollee is at her highest level of function realistically attainable. 
 
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 additional services. Our physician 
reviewer found that there is no documentation that the requested therapy is generally accepted as specific and 
effective therapy for the enrollees condition. After forty treatments, the enrollee has shown little improvement 
and continues to have similar deficits in balance, strength and stability. Further therapy does not appear to be 
indicated, 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 additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy visits.