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

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 2, 2020, to 
December 3, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that at the time of the admission the 
enrollee was treated according to standards and his physicians were not aware at the time that he would decline 
any intervention/heroic measures. The enrollee was admitted based on the fact that he would require more than 
two days of observation. The Plan denied your request. The Plan says that inpatient admission was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the hospital due to subdural hematoma. The enrollee was admitted to 
the neurosurgery intensive care unit due to the severity of this condition. This would normally require a 
hospital stay that would be expected to a least cross 2 midnights due to the need for close observation and 
treatment in an inpatient setting. The fact that the enrollee and family decided to leave early was not expected 
at the time of admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from December 2, 2020, to December 3, 2020.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care 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 in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not need any skilled nursing services; the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. You do not need skilled physical therapy (PT) and occupational therapy (OT) services daily in an inpatient 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 criteria for LTACH admission. The Plan denied your request. The Plan says the records do not show that it is medically necessary to be in an LTACH in place of an acute care hospital
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 that the enrollee appears to be improving and stable and only requires short-term additional acute care services to completed treatment which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already provided and available at the current facility. Therefore, this request for LTACH will be considered not medically necessary as there is no advantage to transfer at this time. Transfer to a lower level of care may be considered when treatment has completed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve 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.
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation services are medically necessary for this enrollee. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met; the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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 while the enrollee may benefit from continued physical and occupational
therapies, there is no evidence of a need for an intensive therapy program of at least three hours per day with
frequent physician oversight and an interdisciplinary approach to rehabilitation care at their current level of
function.
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 servic
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back nerve ablation services.
You asked the Plan to pre-approve the back nerve ablation services. You say that the records provided support the need for the requested services. The Plan denied your request. The Plan says the requested procedure is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the back nerve ablation services. Our reviewer says that back nerve ablation services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back and had an L5-S1 disc replacement. He takes Tylenol and Hydrocodone for pain. He has tried physical therapy, Chiropractic care, Acupuncture and massage therapy. He has Modic changes at 2 levels and the request is for basivertebral nerve radiofrequency ablation (RFA). This is an experimental/ investigational procedure. 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 back nerve ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve back nerve ablation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies and materials (99070) provided from September 28, 2020, to November 9, 2020.
You asked the Plan to pay for the supplies and materials. You say that no dental work was performed or needed. The Plan denied your request. The Plan says payment for supplies and materials (99070) is always bundled into payment for other services not specified and no separate payment is made. The Plan also says that out-of-network approval is not applied to non-covered services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code 99070 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this code is always bundled into payment for other services provided on the date of service. No separate payment can be made for this code. Based on this information, we decided that Medicare rules for coverage of the supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the supplies and materials (99070) provided from September 28, 2020, to November 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Kyphoplasty (CPT code(s): 22512 and 22513), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee is being seen for colon cancer and upon workup, the enrollee had computerized tomography (CT) chest and was found to have a nondisplaced T6 vertebral body fracture. The Plan denied your request. The Plan says that the lack of required information does not establish medical necessity and the services are deemed not reasonable or necessary at this time.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found the enrollee has a pathologic T6 compression fracture from cancer. Magnetic resonance imaging (MRI) is not needed to show edema as the fracture is from cancer. Kyphoplasty will relieve the fracture pain and should be approved. Numerous studies support cement for cancer of spine fracture 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 the services have been met. Therefore, we decided that the Plan has to pre-approve the Kyphoplasty (CPT code(s): 22512 and 22513), for the enrollee.
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 enrollee is stable and clearly exceeds the CMS established defining criteria for appropriate LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH.
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 appears to be improving and stable and only requires a short-term additional acute care services to completed treatment which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already provided and available at the current
facility. There is no advantage to transfer at this time. Transfer may be considered when treatment has
completed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you believe if work out with a physical therapist and an occupational therapist for a limited period of time, you will be fine and can go home by yourself. The Plan denied your request. The Plan says you do not meet Medicare rules for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 requires 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 a SNF admission.
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 IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 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 that you have a past medical history of hypertension, rheumatoid arthritis, neuropathy, and a sacral pressure ulcer. Currently, you are living at home with progressive weakness, buckling of left knee and difficulty ambulating. You are receiving 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. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. IN conclusion, 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says there are not enough studies showing the Vertiflex is safe and effective.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and supplies for the 
enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the member is currently taking 5 insulin 
injections daily and that requires her to check her glucose 6  
times or more a day. The Plan denied your request. The Plan says that that the enrollee does not meet criteria 
for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and 
necessary for enrollees with diabetes who meet criteria referenced 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 a CGM and supplies. Our reviewer says 
that a CGM and supplies are medically reasonable and necessary for the enrollee. The patient has type 2 
diabetes. She has controlled glucose on current medications which include oral meds, Novolog three times 
daily and Lantus twice daily injections. The patient records show the patient requires glucose readings more 
than 5 times per day and requires frequent adjustments in Novolog. Our physician reviewer found that the 
enrollee's condition meets Medicare criteria for a CGM and supplies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CGM and supplies have been met. Therefore, we decided that the Plan has to 
pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.  
 
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 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 an intensive rehabilitation program 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 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 a foot ulcer and had a below the knee amputation. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.
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.