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

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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 an intensive, multi-disciplinary 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office services (CPT code(s): 99214 and 99204) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that you are requesting reconsideration for the outpatient evaluation. The Plan denied your request. The Plan says the enrollee's records received do not indicate that they haves an emergent or urgent medical condition or is in need of specialized service. The Plan states there are in-network provider(s) within a reasonable distance from the enrollee's location that can provide this service or item.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services (CPT code(s): 99214 and 99204) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve total knee arthroplasty, bilateral (CPT code 27447 x2), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary based on the Plan's criteria.  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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria are not met. There is no documentation of a recent trial and failure of physical 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty, bilateral (CPT code 27447 x2), for the enrollee.
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 services are medically necessary. The Plan denied your request. The Plan says the member is receiving appropriate inpatient acute care and does not require transfer to a Long-Term 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 was admitted to the hospital with esophageal perforation complicated by a gastrointestinal bleed, pleural effusion and required Video-assisted thoracoscopic surgery (VATS) complicated by pleural infection and pneumothorax, esophageal stent migration, anemia, dysphagia. He required blood transfusion, G-tube feeds, and antibiotics. Recent notes describe the enrollee as gradually improving. The enrollee appears to be improving and should require only short-term additional acute care hospital services that can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary at this time as it would not be advantageous. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.  You asked the Plan to pre-approve the home ventilator. You say that the enrollee would benefit significantly from the home ventilator's use. The Plan denied your request. The Plan says you prescribed a ventilator to help the enrollee's breathing at various times of the day (night and day) because of the enrollee's lung disease. The Plan states Medicare does not cover ventilators used in this way and Medicare will cover a device called respiratory assist device that as advanced features and the plan will cover this when medically necessary.  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 the home ventilator. Our physician reviewer found the Life2000 System is not medically necessary. This system is not a true ventilator because it is not capable of providing full ventilatory support. It is designed to reduce work of breathing during activity. There is inadequate evidence that this device is effective in the treatment of chronic obstructive pulmonary disease (COPD) or chronic respiratory failure. Further, the enrollee does not meet Medicare criteria for a home ventilator. The enrollee already has bilevel positive airway pressure (BiPAP), but apparently has not been using it consistently. There is no documentation of BiPAP failure in the outpatient setting while medically stable. The denial is upheld.  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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
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 want to get therapy services at a rehab center and you are currently in the hospital with a broken hip. The Plan denied your request. The Plan says you do not meet criteria for an inpatient rehabilitation stay.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and your 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 addition, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says the member does not meet the Medicare criteria for admission to an IRF. Medicare Guidance says the member must generally require an intensive rehabilitation therapy program. The records show that there is no need for an intensive rehabilitation program. Home physical therapy or physical therapy at a skilled nursing facility may be covered if requested.  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 on review of the available records the enrollee with spinal stenosis, post-surgery is medically stable. There are no nursing needs documented in the record. She does not need 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. At the current functional status, the enrollee needs routine physical therapy (PT) and occupational therapy (OT) and does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. An IRF admission is not medically necessary based on lack of medical complexity, and lack of nursing needs and high functional level. While the enrollee may benefit from PT, and OT, the enrollee's rehabilitation needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility or in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (procedure code 88309) provided to the enrollee on May 11, 2021.  You asked the Plan to pay for the services. You say that the claim was coded correctly. The Plan denied your request. The Plan says this is included in the payment to the facility.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 88309 is "Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity, disarticulation Fetus, with dissection Larynx, partial/total resection - with regional lymph nodes Lung - total/lobe/segment resection Pancreas, total/subtotal resection Prostate, radical resection Small intestine, resection for tumor Soft tissue tumor, extensive resection Stomach - subtotal/total resection for tumor Testis, tumor Tongue/tonsil -resection for tumor Urinary bladder, partial/total resection Uterus, with or without tubes and ovaries, neoplastic Vulva, total/subtotal resection."  We find that CPT code 88309 is not supported in the medical record. Specifically, payment for this code would be included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure code 88309) provided to the enrollee on May 11, 2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility or in-home with 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria. 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs or skilled therapy needs. Your current wound and wound care needs are not documented. You appear to have reached a plateau in function. Daily skilled services are not shown to be 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 appears to be improving overall and should require only short-term additional acute care hospital services that can safely be received at the current facility. There are no services at LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed and the enrollee is more stable.    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 IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that an IRF admission is not medically necessary. The Plan denied your request. The Plan says admission to an AIR does not meet criteria, is not medically necessary, and a lower level of care might be appropriate.  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 stroke and knee pain. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve revascularization procedures (37220, 75630, 37228).  You asked the Plan to pre-approve revascularization procedures. You say that the requested service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the requested service.  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 revascularization procedures. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found upon review of the records, the Computed Tomography Scan (CT) showed new plaque on the right aorto-iliac artery described as "extensive" but without a specific percentage occlusion, worse than previously by 18%. Revascularization procedures are only indicated for symptomatic occlusive disease and do not prevent future disease. Angiogram or ultrasound was not performed to clarify the extent of the extensive plaque. Although the enrollee has a non-healing ulcer in the right leg, there was insufficient evidence documented of a measurable occlusion to suggest the primary cause was the arterial disease to justify this request for revascularization.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revascularization procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve revascularization procedures (37220, 75630, 37228).