Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of excess skin of the arms and thighs following weight loss.
You asked the Plan to pre-approve the surgical skin removal. You say that you do not feel that these procedures are cosmetic. You believe that they are medically necessary for your condition. The Plan denied your request. The Plan says this is a cosmetic procedure which is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 surgical skin removal. Our reviewer says that the documentation indicates that the requested procedure is not medically reasonable and necessary. Our reviewer found the record indicates that the enrollee had massive weight loss after bariatric surgery. The provided records do not indicate that there is functional impairment of the arms and thighs. The record does not indicate the presence of intertrigo. The requested procedures are considered cosmetic. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical skin removal have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical removal of excess skin of the arms and thighs following weight loss.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions (CPT code 37766), for the enrollee.
You asked the Plan to pre-approve the service. You say that the services are medically necessary. The Plan denied your request. The Plan says in order for the requested services to be covered, the enrollee would need to have medical records documenting failed conservative management.
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 service. Our physician reviewer found the records show that the enrollee had failed six (6) months of compression therapy, and failed weight loss efforts, however, there was no documentation regarding which methods were tried for weight loss or for how long which is required. Therefore, this request for phlebectomy will be considered 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions (CPT code 37766), for the enrollee.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 you are receiving appropriate care at the present acute care hospital. 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. 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with neurological symptoms form a subdural hematoma. The enrollee has had a prolonged hospital course. The enrollee continues to receive acute care services. The documentation does not indicate that the enrollee requires services that the enrollee is not currently receiving 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 continues to receive acute care services, and these have not been denied. The medical records do not indicate that the enrollee requires services that he 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 enrollee was admitted for thoracic laminectomy and fusion. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. 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. Therefore, the enrollee does not meet criteria for the requested 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power scooter (CPT code K0800), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee is in need of a scooter in order to maintain your activities of daily living and that the enrollee is unable to move around their house effectively without this device. You state the enrollee would benefit greatly and their quality of life would be much greater if this device was approved. The Plan denied your request. The Plan says the records include an office note and appeal from the enrollee's provider that state the enrollee needs the power scooter, but there is no standard written order, any explanation why a cane, walker, or manual wheelchair would not meet the enrollee's needs, home evaluation, or assessment by a DME company. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The records include an office note and appeal from the provider that state the enrollee needs the power scooter, but there is no standard written order, any explanation why a cane, walker, or manual wheelchair would not meet the enrollee's needs, home evaluation, or assessment by a DME company. Therefore, we decided that the Plan does not have to pre-approve the power scooter (CPT code K0800), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of October 6, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee is not yet safe to go home and is a danger to others. The Plan denied your request. The Plan says the denial of authorization for continued inpatient level of care is correct, because the enrollee is stable and can be treated in a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of October 6, 2021. Our physician reviewer found it is not expected that this enrollee will improve in a reasonable period of time beyond the date in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations, or aggressive behaviors while not showing any acute threats to safety. The enrollee was cooperative and compliant with treatment described as being calm, polite, and compliant. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the date in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of October 6, 2021.
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 needs therapy. The Plan denied your request. The Plan says the medical record does not indicate that the enrollee will benefit from and improve with LTACH program care.
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 is more stable but has an overall poor prognosis and requires only short term additional acute care services until long-term placement is determined. The enrollee 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 enrollee requires that are not already available and covered at the current facility. Therefore, LTACH will be considered not medically necessary as there is no notable advantage to transfer there at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 is ready to admit to the IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing facility, home health, or outpatient therapy. 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 need help getting back to normal function. The Plan denied your request. The Plan says the medical records do not support the need for an intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per week.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SPECT (78803) and a bone imaging of the whole body (78306).
You asked the Plan to pre-approve the SPECT and bone imaging. The Plan denied your request. The Plan says the requested imaging is not medically necessary and does not satisfy the Plan's criteria for coverage.
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 SPECT and bone imaging. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that the enrollee has a history of breast cancer and lung cancer. Our reviewer found that the enrollee had a computed tomography (CT) positron emission tomography (PET) scan in August 2021. Our physician reviewer also found that the provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested repeat service. 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 SPECT and bone imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a SPECT (78803) and a bone imaging of the whole body (78306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265), for the enrollee.
You asked the Plan to pre-approve the total electric hospital bed. You say that the enrollee needs to receive the bed to improve their quality of life. The Plan denied your request. The Plan says this bed is not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health physical therapy (PT) visits (G0151).
You asked the Plan to pre-approve the home health visits. You say that the enrollee benefit from skilled PT to address poor strength, balance, stability, coordination, endurance, gait and motor function. The Plan denied your request. The Plan says the records do not support the need for a skilled physical therapist to make more home visits at this time.
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 the home health visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 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 the home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health physical therapy (PT) visits (G0151).
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 you are only able to walk 10 feet with a walker, and continued therapy will bring you closer to your baseline. The Plan denied your request. The Plan says that the denial of authorization for SNF care is correct.
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 you meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled nursing needs. However, you do have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You appear to be functioning below your baseline. There is no evidence that you have reached a new plateau in function. Daily skilled services are reasonably required to establish a maintenance program or to prevent deterioration of your 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.