Persius/hicric huggingface dataset:
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 meets LTACH admission criteria under CMS guidelines. The Plan denied your request. The Plan says the services the enrollee needs could be provided in another setting, such as an acute rehab facility, skilled nursing facility, nursing facility, outpatient setting or home.
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 in this case the enrollee was admitted with septic shock and hypoxic respiratory failure. The enrollee has healing wounds and is extubated. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466). You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says the requested device is being used in the bilevel PAP mode rather than being used as a home ventilator. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Specifically, this item is being requested to use as a bi-level CPAP which is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cardiomems. You asked the Plan to pre-approve Cardiomems. You say that you know when you need something done. You also say that you don't understand why this service is being denied. The Plan denied your request. The Plan says the requested services are not medically necessary. 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 Cardiomems. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a history of non-ischemic cardiomyopathy with ejection fraction equal to 25%. You have chronic atrial fibrillation and moderate renal insufficiency. You are on guideline directed medical therapy which is being titrated due to mild hypotension and some dizziness. You complain of persistent Class III symptoms but has had no hospitalizations for decompensated congestive heart failure in the past 12 months. Although you have a reduced ejection fraction and persistent symptoms of dyspnea on guideline directed medical therapy, you have not been hospitalized in the past twelve months for decompensated congestive heart failure (per office note of April 28, 2021) and your most recent exam at the May 2021 visit reveled no clinical signs of congestive heart failure (clear lungs, jugular venous pressure not elevated, no edema) on exam. Therefore, you do not meet criteria for the requested 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 Cardiomems have not been met. Therefore, we decided that the Plan does not have to pre-approve Cardiomems.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips. You asked the Plan to pre-approve additional routine transporation trips. You say that you are requesting the trips to attend medical appointments. The Plan denied your request. The Plan says this benefit only allows 52 trips for this service and you have exceeded the benefit limit.
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. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. This request exceeds the routine transportation benefit. Your 2021 EOC states that the Plan covers up to fifty-two (52) one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy - anterior on tooth # 7 (CPT code D3346) and core buildup, including any pins when required on tooth #7 (CPT code D2950). You asked the Plan to pre-approve the dental services. You say that you are having severe pain, living through difficult times, suffering from chronic progressive arthritis and can no longer tolerate pain. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. 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 requested items or services are not among those covered under this benefit. The services are not listed in your 2021 Dental Benefit Schedule as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve retreatment of previous root canal therapy - anterior on tooth # 7 (CPT code D3346) and core buildup, including any pins when required on tooth #7 (CPT code D2950).
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 without rehabilitation you will not be able to move around on your own and would need help with getting around to your everyday living. 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 a hip fracture after a fall. You received inpatient rehabilitation care, then skilled nursing care and then were discharged home. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need rehab and physical therapy before returning home. The Plan denied your request. The Plan says you do not need to be seen by a rehab doctor at least 3 times a week or an intensive team for care. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not 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 the enrollee is a 38-year-old woman for whom admission to a long-term acute care hospital (LTACH) has been requested. The enrollee has a medical history of diabetes, cirrhosis, and chronic pancreatitis. The enrollee was transferred to the current acute care hospital on June 16, 2021 with decompensated alcoholic liver cirrhosis, spontaneous bacterial peritonitis, hepatic encephalopathy, and coagulopathy. attempted drainage of an abscess was unsuccessful.
As of July 19, 2021, the enrollee was receiving treatment for bacteremia and Candida sepsis. The enrollee's mental status was good. A feeding tube has been removed. Supportive care is to be continued. 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. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 she is currently receiving care. 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) skilled nursing home health visits.
You asked the Plan to pre-approve skilled nursing home health visits. You say that your hips, knees and seizures are getting worse. You state you cannot walk or stand for very long, sometimes you forget to take your
medications; therefore, you need therapy to regain function. The Plan denied your request. The Plan says the
Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of skilled nursing home health visits have not been met. There were no medical records provided to
verify medical necessity. Therefore, we decided that the Plan does not have to pre-approve twelve (12) skilled
nursing home health visits
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit. 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 medically necessary. The Plan must follow Medicare rules. The rules say that Retacrit is covered for specific indications only. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pancytopenia of an unspecified cause. She does not have a diagnosis for which Retacrit is covered. The services are therefore not reasonable 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in this case does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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. Specifically, medically necessary services are being obtained at the enrollee's current level of care. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency
transport (A0428).
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the enrollee needs
treatment to sustain life and needs ambulance/stretcher transportation. The Plan denied your request. The Plan
says the enrollee does not meet criteria for ambulance transportation
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 non-emergency ambulance
transportation. Our reviewer says that the service is not medically necessary. Our physician reviewer found that
in this case, the record indicates that the enrollee requires transportation to hemodialysis three times weekly.
The medical necessity and reasonableness, as defined by Medicare rules, of the requested service is not
supported by the records. The record does not indicate that a lower level of transportation such as wheelchair or
stretcher van is contraindicated for the enrollee. The elements of the coverage criteria are not satisfied. The
requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we
decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency
transport (A0428).
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 you are a new amputee and you have not been trained to walk and you are at a high risk for falling. You state you do not have the equipment you need at home and you have no one to assist you at home. 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 a below the knee amputation. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but
there is no documented need for an intensive rehabilitation program. Medically necessary services can be
provided in a different level of care. There is not a reasonable expectation that you will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of low back pain, heart disease and bipolar disorder and is living at home with ongoing weakness and trouble walking despite home health physical therapy. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.