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 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 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, you are
mostly minimal/contact guard assist for functional transfers and activities of daily living (ADL's) and a less
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and
predicted period. An IRF intensity is not warranted.
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 left side facet joint injections (64490, 64491, 64492).
You asked the Plan to pre-approve left side facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered with the above frequency limitations. 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 left side facet joint injections. Our reviewer says that this request exceeds the frequency limitations for this service. Our physician reviewer found no more than 4 therapeutic facet joint nerve blocks per year are reimbursable with 2 levels per region, per session after the appropriate documentation of 80% improvement with diagnostic blocks for the duration of the local anesthetic, and with a total relief and improvement of at least 50% of 6 weeks (including > 80% relief and > 50% relief). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left side facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve left side facet joint injections (64490, 64491, 64492).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
You asked the Plan to pre-approve 10 additional occupational therapy visits. You say that additional visits are medically necessary. The Plan denied your request. The Plan says additional therapy is 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 10 additional occupational 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 had therapy and a caregiver has been given training and education. 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 10 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a SNF.
You asked the Plan to pre-approve the SNF admission. You say that you are falling frequently at home. You also say that your doctor suggested that you have physical therapy to strengthen your lower extremities to prevent any accidents. The Plan denied your request. The Plan says the criteria for a SNF admission has not been 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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.
Therefore, we decided that the Plan does not have to pre-approve admission to a 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 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 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 there is no documentation provided requiring admission to a LTACH. The review has
determined that you do not require services at the LTACH that are not available at the acute care hospital
where you are currently receiving care. There are no services available at the LTACH that you require that are
not available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished
safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Xofigo radiation.
You asked the Plan to pre-approve these services. You say that the services are medically necessasry. The Plan
denied your request. The Plan says that the services are not medically necessasry.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are medically necessasry. Our physician reviewer found the enrollee has a diagnosis of metastatic
hormone-sensitive Gleason 9B prostate cancer. The National Comprehensive Cancer Network (NCCN)
guidelines consider Radium-223 a category one recommendation as a first or second line therapy for metastatic
prostate cancer without visceral metastases. The requested Xofigo is the standard of care and reasonable and
medically necessary for the enrollee's condition.
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 been met. Therefore, we decided that the Plan has to preapprove
Xofigo radiation.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 6, 2020 for evaluation and treatment of acute respiratory distress syndrome secondary to e. coli pneumonia and COVID-19 virus. He required intubation and underwent a tracheostomy and PEG tube placement. On August 19, 2020 the chest tube was still in place and there was ongoing drainage. The review indicates that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Ascent injection.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a 10 year history of left knee pain. The requested Ascent injection is considered experimental in nature, as more research is needed to show the efficacy and safety. 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 an Ascent injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, or home with home health 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 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 treatment of pneumonia and urinary tract infection. Medical problems are stable and no longer require inpatient management. 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. Although physical and occupational therapy is appropriate for the enrollee's clinical condition, this therapy does not require 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vest for a pneumatic compression device (PCD).
You asked the Plan to pre-approve these services. You say that you have trouble picking things up. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a PCD vest is covered when 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have post-mastectomy of lymphedema of the right arm and surgical and radiation lymphedema. The report dated July 1, 2020 states no lower limb edema and you have 1+ right arm edema. The records do not support that the vest is reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a vest for a pneumatic compression device (PCD).
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 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly maximum assist for functional transfers and activities of daily living (ADL's) 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: 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 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 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 4, 2020 after a fall with an open Pilon fracture, fifth metatarsal base fracture, and distal tibia
and fibula fractures. He underwent surgical repair and is now non-weight bearing on the left lower extremity.
The pre-admission screening dated August 6, 2020 states he requires minimal to modified assist for bed
mobility, transfers, and upper body dressing and minimal assist with lower body dressing. The level of care he
requires is not appropriate for an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. There is not a reasonable expectation that he will able to fully participate in and benefit
from 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the brain.
You asked the Plan to pre-approve MRI. You say that you feel this service is medically necessary. The Plan denied your request. The Plan says the denial of authorization for the requested MRI is correct.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found there were not any signs, symptoms, or physical examination findings to support the need for an MRI of the brain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the brain.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT, lower extremity; without contrast material (CPT
Code 73700), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the CT scan is needed for pre-op mapping and
planning of the joint replacement. The Plan denied your request. The Plan says the Medicare rules have not
been met.
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our physician reviewer
found criteria for the CT scan are not met. There is no evidence that robotic knee surgery is better than
conventional knee surgery. The CT scan 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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CT, lower extremity; without contrast material (CPT Code 73700), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you would benefit from rehab. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital on August 14, 2020 for low blood sodium (hyponatremia) and rapid heartrate (paroxysmal atrial fibrillation). You received oral medications and had stable vital signs. You received physical and occupational therapy in the hospital and need assistance with walking 110 feet and activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require these services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.