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 enrollee meets the criteria for admission to an IRF, and these services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the homocysteine (CPT code 83090) provided to the enrollee
on September 10, 2020.

You asked the Plan to pay for the homocysteine. You say that the service should be paid. The Plan denied your
request. The Plan says with the information they have, they cannot determine a physician's order was given,
how the enrollee came to you, the referring provider, and/or whether the services are necessary.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 83090 is not supported in the medical record. Specifically, we cannot verify if the
service was necessary with the information provided. Based on this information, we decided that Medicare
rules for coverage of the homocysteine have not been met. Therefore, we decided that the Plan does not have to
pay for the homocysteine (CPT code 83090) provided to the enrollee on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan (skeletal survey) for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this request is not safe and effective for a patient exposed to a lot of radiation, without signs and symptoms of myeloma.

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 scan. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found the enrollee is asymptomatic and has normal laboratory values. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's specific clinical condition. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan (skeletal survey) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the services. You say that this level of care is needed. The Plan denied your request. The Plan says the medical records do not establish the necessity of these 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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee is ambulating more than 100 feet, and tending to ADLs with minimal supervision. Daily skilled services are not necessary to establish a maintenance program, or to prevent deterioration of the enrollee's condition. Care needs, as a practical matter, can be provided at a lower level of care, such as home health, assisted living, or long term 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the request 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 there is no documentation indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the 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 the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis (74178).

You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is not medically necessary.

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 a CT scan of the abdomen and pelvis. Our reviewer says that the requested CT scan is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is being treated for a urinary tract infection (UTI). The requested test is not indicated for hematuria (blood in urine) if the enrollee currently has a UTI. Blood in urine can happen with a UTI. There is no specific clinical rationale for the requested CT scan. 

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 CT scan of the abdomen and pelvis have not been met.

Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis (74178).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there appears to be some concern that the devices are not as effective as surgical decompression, and could lead to higher rates of reoperation.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device 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 RF care is medically necessary. The Plan denied
your request. The Plan says the criteria for an admission to an IRF are not met. You can safely receive the
services you need in another 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 your 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 are a 62-year-old male who has a history of hypertension, chronic obstructive pulmonary disease, and other conditions. Currently, the enrollee has been in an inpatient rehabilitation facility. Based on the documentation provided, you do not have documented skilled nursing needs. Furthermore, you do not have documented skilled therapy needs. You have reached a new baseline of function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a history of
pseudotumor cerebri and associated headaches, dizziness, and ringing in ear. She is being treated with lumbar
punctures and there is a plan for a lumbar peritoneal shunt. Although imagine is warranted, magnetic resonance
imaging (MRI) of CT myelogram is more appropriate to clearly rule out cerebrospinal fluid (CSF) leak or
fistula, as current evidence is more supportive of his imaging compared to CT. The CT scan is therefore not
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a computed tomography (CT) scan of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical total disc arthroplasty C4-C5, C5-C6 for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found two level disc replacement surgery remains experimental. It is only FDA-approved for one level. More long-term outcomes research is needed.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical total disc arthroplasty C4-C5, C5-C6 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of a gait evaluation. The documentation is not clear that there was true instability on an objective physical exam. The documentation does not indicate any pathological laxity, with objective measurements of any laxity of the knee. There is no evidence of a recent injury or surgery to the knee. The documentation is not clear that the enrollee is ambulatory, and there is no evidence that the enrollee requires the requested brace.

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 a knee orthosis (L1843) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ambulatory insulin infusion pump (E0784) to be provided by an out-of-network provider.

You asked the Plan to pre-approve an ambulatory insulin infusion pump. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an ambulatory insulin infusion pump (E0784) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic consultation with a dentist or physician other than the requesting dentist or physician (D9310).

You asked the Plan to pre-approve a diagnostic consultation. You say that this consultation is medically necessary. The Plan denied your request. The Plan says this service is not covered by your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a diagnostic consultation with a dentist or physician other than the requesting dentist or physician (D9310).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment (CPT code(s): 81404 and
81479) provided to the enrollee on October 30, 2020.

You asked the Plan to pay for the testing. You say that the denied codes should be processed. The Plan denied
your request. The Plan says the service is not covered.

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.

Review of the available clinical case notes and records presented for an appeal of cardiovascular-respiratory
risk assessment testing has been completed. Medicare denies coverage for all cardiovascular risk assessment
testing / panels for suspected or documented cardiovascular disease. Therefore, we decided that the Plan does
not have to pay for the cardiovascular risk assessment (CPT code(s): 81404 and 81479) provided to the enrollee
on October 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve a continuation of SNF services. You say that the enrollee is still under care
and needs services at the SNF level. The Plan denied your request. The Plan says the guidelines for continued
SNF care have not been met.

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 a continuation of SNF services. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found As of September 15,
2021, the enrollee did not require any skilled nursing or rehab services on a daily basis. She was not expected
to make measurable gains within a reasonable and predictable period of time or require skilled therapy to
prevent deterioration with mobility or activities of daily living (ADLs). The enrollee did not require skilled
therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not
require any skilled services on an inpatient basis, at a SNF level of care as of September 15, 2021. The enrollee
did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee
received skilled care and improved; however, her function had plateaued by September 15, 2021, and she did
not require any further inpatient skilled rehab services. The enrollee's function was at or near her prior level of
function and she could be discharged to a lower level of care for further services. As of September 15, 2021,
the enrollee required custodial 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 a continuation of SNF services have not been met. Therefore, we decided that
the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.