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 care and therapy you need can only be done at an IRF. The Plan denied your request. The Plan says under Medicare, your request 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
You asked the Plan to pre-approve TMS. You say that the requested TMS is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested TMS.
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 TMS. Our reviewer says that the enrollee does not meet criteria for the requested TMS. Our physician reviewer found the enrollee's treating physician is requesting coverage for 36 sessions of Transcranial Magnetic Stimulation (TMS) (90867 x 1 and 90868 x 34 and 90869 x 1) for Major Depressive Disorder, Recurrent, Severe. Based on review of the records provided and utilizing the Medicare local coverage determination LCD specifically for Transcranial Magnetic Stimulation ((TMS) (L34998) specifically requires the confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent as well as resistance to the treatment with pharmacologic agents as evidenced by lack of clinical significant response to 4 trials of pharmacologic agents in the current depressive episode from at least two different agent classes along with concurrent documented psychotherapy. Documentation presented has not specified a clear diagnosis as the enrollee has had several the past few years. She had been tried on a number of pharmacologic agents from different categories including lorazepam, Invega, Effexor, BuSpar, Depakote, Neurontin and Zyprexa however it is unclear if these agents had been used in the same "depressive" episode. The enrollee has no clear documentation of psychotherapy and no documentation of standardized depressive rating scales for this enrollee. Utilizing the information from this enrollee that indicates this enrollee does have an indication for the requested Transcranial Magnetic Stimulation (TMS) this enrollee does not meet the LCD requirement for Transcranial Magnetic Stimulation (TMS) in the treatment of Major Depressive Disorder therefore it is not medically reasonable or 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 TMS have not been met. Therefore, we decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve the electronic knee and advanced foot and ankle. We decided that the Plan does not have to pre-approve the advanced foot and ankle.
You asked the Plan to pre-approve the electronic knee and advanced foot and ankle. You say that you would like reconsideration because the requested prostheses are medically necessary. The Plan says that the notes do not support the need for an electronic knee or advanced foot and ankle.
We decided that the Plan has to pre-approve the electronic knee.
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee is covered for beneficiaries whose functional level is 3 or above. 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 electronic knee. Our reviewer says that based on the prescribing physician's note in the medical records provided, there is documentation that the enrollee is a K3 level ambulator. The electronic knee is the most appropriate knee for her to be able to walk and function safely. 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 electronic knee have been met. Therefore, we decided that the Plan has to pre-approve the electronic knee.
We also decided that the Plan does not have to pre-approve the advanced foot and ankle.
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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 advanced foot and ankle. Our physician reviewer found the advanced foot and ankle feature is not addressed by the prescriber in the records provided. The criteria for approval of the advanced foot and ankle feature are not met. 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 advanced foot and ankle have not been met. Therefore, we decided that the Plan does not have to pre-approve the advanced foot and ankle.
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 LTACH level of care is the only option for a safe discharge for the enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH 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 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. 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: 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 the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: Other
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).

You asked the Plan to pre-approve stereotactic body radiation therapy (SBRT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that SBRT is covered for certain indications.

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 stereotactic body radiation therapy
(SBRT). Our reviewer says that the documentation does support that the requested services are medically
reasonable and necessary. Our physician reviewer found the enrollee has only one other site of metastatic
disease. A likely metastatic lesion in the liver has regressed with systemic therapy. The enrollee therefore only
has what appears to be one site of active metastasis. The appeal letter also describes the need to use tight
margins to minimize normal tissue exposure in this enrollee with a complex metastatic lesion. The delivered
dose is relatively low (5 Gy x 5) given the proximity to bowel in this patient with an ileal conduit and low lying
bowel after cystectomy. In many respects, this case is 'borderline' with respect to whether or not SBRT would
be a standard of care approach. The presence of another lesion (in the liver) that is not to be treated, and the
inability to escalate the dose to that typically used for SBRT raise some question on the use of SBRT.
Nevertheless, in an enrollee with limited metastases, of which only one is symptomatic and progressive, and
the intent to escalate the dose beyond typical palliation (which would be 4 Gy x 5) suggest that SBRT would be
furnished in accordance with accepted standards of care. Therefore, the enrollee meets criteria for the requested
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 stereotactic body radiation therapy (SBRT) have been met. Therefore, we
decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).

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: 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 require the intensity of services provided at an IRF.
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 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 a continued SNF admission.
You asked the Plan to pre-approve the continued SNF admission. You say that you are not strong enough to be discharged and need more therapy. The Plan denied your request. The Plan says your request for approval of continued admission in SNF does not meet the requirements for approval.
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 continued SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the continued SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued SNF admission.
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 you need more therapy than just three times a week. The Plan denied your request. The Plan says an IRF 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 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. You were admitted for pneumonia and were discharged home with home health on September 19, 2021. 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 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 IRF admission and 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 is receiving appropriate care at the present acute care hospital. 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) imaging of the abdomen.
You asked the Plan to pre-approve the abdominal CT scan. You say that it is felt this imaging is needed. The Plan denied your request. The Plan says a CT scan of the chest is approved; however, there is no clinical indication for abdominal CT imaging.
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 abdominal CT scan. Our reviewer says that the requested imaging is not considered reasonable and necessary in this case. Our physician reviewer found the review indicates that according to the clinical documentation, there is no indication for repeating an abdominal CT for this member who has no symptoms and had an incidental and very non-specific finding of fat stranding on a prior abdominal CT 17 months ago. Additionally, recent labs in 2021 were essentially normal. The review indicates that the requested abdominal CT scan is not medically reasonable or 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 abdominal CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) imaging of the abdomen.
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 an IRF 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 that based on review of the available records, you do not meet Medicare coverage criteria for an IRF admission. You are medically stable after an uncomplicated femur fracture and surgery and does not need physician's supervision 3 times a week. There are no documented skilled nursing needs.
The medical documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day, at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. An IRF admission is not medically necessary based on lack of medical complexity and lack of skilled nursing needs. While you may benefit from physical therapy and occupational therapy, your therapy needs can be addressed at a lower intensity 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this procedure would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this is helpful for treatment of the enrollee's condition.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.