Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five visits of home health physical therapy (G0151)
You asked the Plan to pre-approve five visits of home health physical therapy. 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 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 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 five visits of home health physical therapy. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation that the five additional home health physical therapy visits are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five visits of home health physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve five visits of home health physical therapy (G0151)
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 is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/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 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. 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: 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 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 members medical conditions are stable and they have no complex nursing or
rehabilitation needs. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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. Specifically, medically necessary services can be obtained in a lower level of care. 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 skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your records do not show that you require daily skilled services that can
only be provided on an inpatient basis.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 you do not require skilled services on a daily basis or 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. Specifically, medically necessary services can be obtained at a lower level of care. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
You asked the Plan to pre-approve Keytruda. You say that the enrollee's bone marrow is unlikely to tolerate
additional cytotoxic therapy. The Plan denied your request. The Plan says the clinical value for the enrollee's
condition has not been demonstrated in peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Keytruda. Our physician reviewer
found that the enrollee has stage III ovarian cancer. The requested use of Keytruda is not FDA-approved for the
enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that
appears in a CMS-approved medical journal. The enrollee does not meet criteria with a low tumor mutational
burden (TMB) and stable microsatellite (MSI). The use is not listed as not indicated, not supported or not
recommended in any of the compendia. The documentation does not support that the requested drug is safe and
effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve pembrolizumab (Keytruda).
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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that 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.
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 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 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 your medical conditions are stable and you have no complex nursing or rehabilitation
needs.
While you may have a need for physical and/or occupational therapy, there is no documentation of a need for
an intensive rehabilitation program.
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. Specifically, medically necessary services can be
obtained in a lower level of care. Therefore, we decided that the Plan does not have to pre-approve acute
inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve A push-rim activated power assist device (E0986) and repairs (K0739).
You asked the Plan to pre-approve A push-rim activated power assist device and repairs. You say that the item is medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for this item.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 push-rim activated power assist device and repairs. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do not have a personal mobility deficit that impairs participation in MRADLs and it is not clear if you can safely operate a PMD. You had a specialty evaluation that was performed by PT and that documents the need for the device in your home, although the need may be temporary as you recover from recent illness. It is not known if you would tolerate a light-weight manual wheelchair instead of the powered wheelchair. The provided records did not clearly show if the wheelchair was provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection. 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 push-rim activated power assist device and repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve A push-rim activated power assist device (E0986) and repairs (K0739).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are not in shape to go home. The Plan
denied your request. The Plan says you no longer require skilled services.
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 services. Our physician reviewer
found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated
for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at
a maximal assist to contact guard assist level with functional mobility. You required varying assist with
activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria
for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) 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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is an 85-year-old female who was admitted to the acute care hospital with subarachnoid hemorrhage, subdural hematoma, multiple fractures following a fall at home. She required ventriculostomy and intubation and started on Keppra. Magnetic resonance imaging (MRI) scan of the brain showed diffuse axonal injury. The course was complicated by leukocytosis/infection requiring antibiotics and pneumothorax requiring chest tube. Palliative care consulted due to poor prognosis. Pressure support trials were recently initiated. The patient appears to not be improving and only requires short-term additional acute care services that can be safely administered at the current facility for additional weaning trials and to determine a more appropriate placement. The patient does not require services at the LTACH that are not
already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered soon 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 the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. 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 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 care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled
nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF.
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 SNF care have not been met. Specifically, medically necessary services can
be obtained in a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore,
we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a leadless pacemaker (33274).
You asked the Plan to pre-approve the insertion of a leadless pacemaker. You say that the service is medically necessary. The Plan denied your request. The Plan says the service requested does not meet the requirements for approval.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. 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 insertion of a leadless pacemaker. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show that the member is enrolled in a CMS approved study. 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 insertion of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a leadless pacemaker (33274).
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 IRF care is medically necessary for the enrollee's condition. 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 the patient was admitted for metabolic encephalopathy, coronavirus, urinary tract
infection, and dehydration. Medical problems are stable. There are no complex nursing or rehabilitation needs. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. 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 were admitted for sepsis and a pleural effusion. Medical problems 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.
While you have a need for physical and/or occupational therapy, there is no documentation of a need for an
intensive rehabilitation program. 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.