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 IRF care is needed for the enrollee to regain his independence. The Plan denied your request. The Plan says the criteria for admission to the IRF setting 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 at the current medical stability and lack of medical complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. Based upon the enrollee's current level of function, he does not require an intensive, complex, multidisciplinary approach to daily therapy. The enrollee needs physical therapy and occupational therapy in an alternate low intensity level. With bladder and bowel incontinence and cognitive deficits, it is unlikely that the enrollee can function independently in the community with IRF admission. The enrollee does not need a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. An IRF admission is not medically necessary. While the enrollee may benefit from physical and occupational therapy, his rehabilitation needs can be safely met in an alternate and low intensity 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy is only medically necessary for diagnostic or surveillance purposes as a secondary procedure when the diagnostic optic colonoscopy is incomplete. 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 wireless capsule endoscopy. Our reviewer says that requested wireless capsule endoscopy does not meet the criteria for coverage. Our physician reviewer found the requested procedure is ordered as a secondary procedure. There is no evidence of an incomplete diagnostic optical colonoscopy. Therefore, the reviewer found that the elements of the coverage criteria have not been 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 a wireless capsule endoscopy have not been met. Specifically, the file does not show evidence of an incomplete diagnostic optical colonoscopy. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. The request is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
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 to an acute care hospital for gastro-intestinal bleeding. Medical problems are stable. 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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 services are medically necessary for this enrollee, who will not receive proper treatment at a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in a less intensive setting.
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 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 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 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 enrollee was admitted to an acute care hospital with hypercapnic and hypoxic
respiratory failure due to obesity hypoventilation syndrome. 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 he is not currently receiving but that would be available at the LTACH facility. The elements of
the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to return home at this time for safety reasons. The Plan denied your request. The Plan says that the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs may be met at a lower level of 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 SNF care. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below his baseline and has not yet been shown to have reached a new plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vitaseq 59 hereditary cancer panel testing.
You asked the Plan to pre-approve hereditary cancer panel testing. You say that being proactive and knowing
the outcome of this testing would be beneficial, and you would be informed of how to go forward with
healthcare decisions be being aware of your genetics. The Plan denied your request.
The Plan says the denial of authorization for this testing is correct, because these are not covered tests for your
history and Lynch Syndrome panel testing is not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The record does not show that the results of this testing are being requested to guide therapeutic decisionmaking
in regards to a specific medical condition. This panel testing is being requested to assess your
hereditary risk for cancer, which is considered non-covered screening. Therefore, we decided that the Plan does
not have to pre-approve Vitaseq 59 hereditary cancer panel testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is 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 the Intracept procedure. Our reviewer says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the Intracept procedure remains experimental for the treatment of low back pain. More research is needed to show safety and efficacy of the procedure. The request is not medically necessary at this time. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
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 the SNF services. You say that you orthostatic is now stable and it is
medically appropriate for discharge. You say that you are now ready to go back to the SNF. The Plan denied
your request. The Plan says SNF care is not medically necessary. The Plan says that the enrollee is not
medically stable for transfer. The Plan says that the enrollee's needs may be met in the hospital setting.
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 services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications and insulin, had stable vital signs, and his lungs were clear. The enrollee received physical therapy
in the acute hospital. The enrollee was at close supervision to minimal assist level with functional mobility,
including gait to short distances. There are no identifiable skilled nursing service needs. There are identifiable
skilled therapy service needs, however they are not required on a daily basis. The enrollee does not meet the
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 the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 Motion orthosis (CPT code L8702).
You asked the Plan to pre-approve the MyoPro 2 Motion orthosis. You say that you have upper extremity
partial paralysis. You state you have engaged in occupational therapy, physical therapy and modalities. You
state that the MyoPro would immediately restore your arm function and range of motion by allowing you to
volitionally control motors at the elbow and hand portions of the brace. The Plan denied your request. The Plan
says other local carriers consider the MyoPro Motion G experimental or investigational in the absence of an
upper extremity partial amputation because of insufficient evidence of its effectiveness. The Plan states there is
insufficient evidence in the literature that indicates that this orthosis is effective for hemiparesis due to a stroke.
The Plan states there were no medical records submitted to document any previous therapeutic interventions or
results or documentation of use of any other types of braces or upper orthoses/braces.
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 MyoPro 2 Motion orthosis. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found there is insufficient evidence in the literature that indicates that this orthosis
is effective for hemiparesis due to a stroke. There were no medical records submitted to document any previous
therapeutic interventions or results or documentation of use of any other types of braces or upper
orthoses/braces. The review has determined that the items/services at issue in this case are not medically
reasonable and 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 the MyoPro 2 Motion orthosis have not been met. Therefore, we decided that
the Plan does not have to pre-approve MyoPro 2 Motion orthosis (CPT code L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 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 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 home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found based on the limited documentation provided, the enrollee is noted to have chronic obstructive pulmonary disease (COPD). There is no evidence that the enrollee has neuromuscular disease or thoracic restrictive disease. There is no evidence that the enrollee has compliantly used standard treatments (i.e. oral meds, inhaled meds,BiPAP/CPAP) resulting in treatment failure. As such, the requested home ventilator is not shown to be medically necessary or reasonable. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an IRF stay, and these services are necessary for the enrollee to return home safely and independently. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can be provided in 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 the enrollee's current medical stability and lack of medical complexity does not require an intensive rehabilitation program with physician supervision at least three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. While the enrollee would benefit from physical therapy and occupational therapy, they do not require an intensive, complex, multidisciplinary approach to daily therapy and these services can be provided in an alternate and low intensity setting. The enrollee does not need a therapy program consisting of at least three hours of therapy per day at least five days per week with an interdisciplinary approach to rehabilitation care. The IRF admission is not medically necessary; the enrollee's rehab needs can be met in a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.