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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care due to his 
prior full functional status. He is participating in therapy and would be best served by an intensive program. 
The Plan denied your request. The Plan says the enrollee does not meet the IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 67-year-old male enrollee presented on 6/24/2020 with COVID pneumonia 
requiring intubation He has had multiple complications since then and is deconditioned. Hospital course 
included COVID management and management of atrial flutter symptoms. Now, his hemodynamics are stable 
and he is tolerating a trach collar with room air, saturating well. He is severely weak, and require moderate to 
maximal assist of two persons for all aspects of care. 
 
In this case, the member is mostly moderate to maximal assist for functional transfers and daily living activities 
and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be 
able to fully benefit and/or participate in an IRF 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that it is vital for the enrollee to 
regain strength and function. You say that physical therapy would help him achieve this. The Plan denied your 
request. The Plan says additional visits are not medically necessary. 
 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy and was 
trained in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not 
required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel Sureclick (J1438). 
 
You asked the Plan to pre-approve Enbrel Sureclick. You say that the enrolleeis stable on this medicaiton. The 
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug team. 
 
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 Enbrel Sureclick (J1438).  
 
Benefits for Enbrel Sureclick 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 admission to inpatient psychiatric care requested on September 12, 2020.

You asked the Plan to pre-approve the inpatient psychiatric admission. You say that inpatient care is medically necessary in this case. The Plan denied your request. The Plan says the documentation supports that outpatient level services would have been sufficient.

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 inpatient psychiatric admission. Our reviewer says that the documentation does not support that the inpatient level of care was medically reasonable and necessary. Our physician reviewer found this 71-year-old male was admitted to the acute inpatient psychiatric hospitalization on September 12, 2020 with Major Depressive Disorder, Recurrent, Severe without Psychosis and Cannabis Use Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis.

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 inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to inpatient psychiatric care requested on September 12, 2020.
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on August 29, 2020 with multiple falls, left lower extremity cellulitis with wound, and severe anemia. 
He was found to have a right colon tumor and was treated in the hospital with surgical consultation and a right 
hemicolectomy. He is medically stable and needs minimum assist for some transfers and moderate assist for 
some activities of daily living. The complexity of his nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He requires 
further therapy but does not require an intensive therapy program 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 it is felt that IRF care is necessary. The Plan denied 
your request. The Plan says the enrollee has no medically complex conditions and does not require intensive 
therapy of up to three hours per day. 
 
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 with admitted to the hospital for an ankle fracture which was treated 
conservatively. She subsequently returned and underwent open reduction and fixation (ORIF) surgery. The 
enrollee 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.  The enrollees 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: 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 cellulitis, 
chronic lower extremity wounds, and atrial fibrillation. From a nursing perspective, the enrollee received oral 
medications. The enrollee had stable vital signs. She had uncomplicated wound care to her lower extremities. 
Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute 
hospital. The enrollee was at a stand by assist level with functional mobility including gait to 150 feet with a 
rolling walker. The enrollee required varying assist with activities of daily living. She worked with speech 
therapy on attention/concentration and cognition. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a 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: 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 IRF care to help 
return to prior level of function. The Plan denied your request. The Plan says the enrollee is medically stable 
and does not require three daily hours of therapy to make measurable gains. 
 
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 admitted to the hospital on 9/13/2020 due to a fall causing a hip 
fracture for which open reduction and fixation (ORIF) was performed. 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 or to require regular physician evaluation.  The enrollees 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from the 
LTACH level of care. The Plan denied your request. The Plan says the enrollee has recently destabilized and is 
not ready for transfer to another facility at this time. 
 
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 patient is a 70 year old female who was admitted to the current acute care 
hospital with pneumonia and acute respiratory failure. She was treated with mechanical ventilation and 
antibiotics and later required PEG tube feeds. She required mucus plug removal via bronchoscopy which 
helped. She has since improved enough to be weaned to a trach mask, however. bacteremia and candida was 
diagnosed recently and was restarted on antibiotic and antifungal medications. 
 
The patient in this case appears to be improving, but still requires additional acute care services. However, the 
documentation does not suggest that the patient is likely to warrant acute care services beyond 24 additional 
days for stabilization and additional weaning. The patient does not require services at the LTACH that are not 
already available at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Continued services at the current facility appears to be most appropriate and 
consideration for transfer can be made soon. 
 
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 chronic 
obstructive pulmonary disease and a fall with femur fracture and surgery. From a nursing perspective, the 
enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain with effect. She 
used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy in the 
home setting. The enrollee was at an independent to supervision level with functional mobility including gait to 
80 feet with a rolling walker.  The enrollee required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a 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: 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). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 the PET scan. Our physician reviewer 
found melanoma would be considered a diagnosis for a PET scan. Although the patient has a history of 
melanoma, successfully treated with immunotherapy and surgical resection, the requested imaging was not 
planned on being used to plan and treat the melanoma any differently as the Nivolumab would have been 
discontinued anyway without additional treatments discussed beside observation, which doesn't warrant a PET 
scan. Therefore, the PET scan 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 PET scan have not been met. 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).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar injections. 
 
You asked the Plan to pre-approve lumbar injections. You say that the injections will help decrease the 
enrollee's inflammation and pain symptoms. The Plan denied your request. The Plan says the enrollee does not 
have at least 3 months of localized pain that does not travel to other areas of the body. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered under certain 
medical indications. 
 
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 lumbar injections. Our physician 
reviewer found that the enrollee has chronic low back pain, lumbar radiculopathy, lumbar intervertebral disc 
displacement, fibromyalgia and osteoarthritis of the right hip. The low back pain is a 9 out of 10 in intensity.  
The pain is sharp, dull, aching and stiff in quality. The pain is worse with bending and prolonged sitting and 
driving. The pain is improved with lying down and rest. The enrollee has received epidural steroid injections 
and trigger point injections with excellent relief. He has been receiving NSAIDs and pain medications. There is 
no documentation of physical therapy. There is non-facet pathology that could explain the source of his pain. 
There is no documentation of a trial of physical therapy as tolerated. Therefore, the requested injections are not 
medically reasonable and necessary to treat 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 lumbar injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve lumbar injections.