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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states your
medical and therapy needs could be met in a skilled nursing unit.
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 management of necrotizing fasciitis of the right thigh and perineum. 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. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation and lodging costs for treatment for mycosis
fungoides for September 8, 2021.
You asked the Plan to pay for the costs. You say that the facility is 80 miles each way from your home. The
Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The plan pays for these costs when needed for transplant services. You were not receiving a transplant for this
case. Based on this information, we decided that Medicare rules for coverage of the costs have not been met.
Therefore, we decided that the Plan does not have to pay for transportation and lodging costs for treatment for
mycosis fungoides for September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states 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 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 rib fracture and hydropneumothorax after a fall. 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. 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 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. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.
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. Our reviewer found that 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. Our physician reviewer also found that 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the special power wheelchair (group 2 power wheelchair) with two (2) or more power seat options (power tilt and power recline) (CPT code(s): K0842, E2311, E2377, E2313, E2361, E1007, E1028, E0955, E1012, and E2603), for the enrollee.
You asked the Plan to pre-approve the DME). You say that the DME is necessary. The Plan denied your request. The Plan says a group 3 power wheelchair with multiple power option and all power controls through the joystick is not medically necessary. The Plan states the enrollee's needs can be met with a group 3 power wheelchair with no power option and a request for a group 3 power wheelchair with no power option can be reviewed if submitted.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 DME. Our physician reviewer found the documentation is not clear that the enrollee's seizures are managed at this time. The December 29, 2021, physician notes states there is an urgent referral to neurologist to quickly manage new onset seizures; therefore, the documentation does not reveal that the enrollee is safe to use the requested power wheelchair. Furthermore, the documentation does not reveal that the enrollee uses a ventilator attached to a wheelchair, is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity; therefore, the request for power tilt and recline exceeds the enrollee's medical needs. The documentation does not support the medical necessity. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the special power wheelchair (group 2 power wheelchair) with two (2) or more power seat options (power tilt and power recline) (CPT code(s): K0842, E2311, E2377, E2313, E2361, E1007, E1028, E0955, E1012, and E2603), 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 the enrollee was admitted to the emergency room for having a stroke and was fully independent before it happened. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for approval.
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sedation for radiofrequency ablation.
You asked the Plan to pre-approve the sedation services. You say that these services are medically necessary. The Plan denied your request. The Plan says it has approved the radiofrequency ablation services, but the sedation is not covered.
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not medically reasonable and necessary for facet joint interventions. Individual consideration may be given in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. 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 sedation services. Our reviewer says that the requested sedation services are not medically necessary. Our physician reviewer found the medical records do not include unequivocal and clear documentation of the medical necessity for sedation. There are no unique circumstances showing the medical necessity of sedation as there was no unequivocal or clear documentation in the medical record.
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 sedation services have not been met. Therefore, we decided that the Plan does not have to pre-approve sedation for radiofrequency ablation.
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 needs IRF care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
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. 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 the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you were independent before your hospitalization,
and you want to return to being independent. The Plan denied your request. The Plan says the stay is not
medically necessary based on IRF criteria. The Plan states you can safely receive the services you need in other
settings, for example: a skilled nursing facility or home with home health services.
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 health plan's denial should be upheld. You do not require the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen (15) 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 IRF admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electrical stimulation device.
You asked the Plan to pre-approve the electrical stimulation device. The Plan denied your request. The Plan says the device is not covered for the member'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 the electrical stimulation device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
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 electrical stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve the electrical stimulation device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs 3 hours of rehabilitation per day at an IRF rather than 1 hour per day at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not demonstrate that she could participate in 3 hours of therapy per day or 15 hours per week nor does she require acute medical care or rehab physician care three days of the 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 the enrollee's 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 the 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to further pay for skilled nursing facility (SNF) services provided from March 20, 2020, to March 31, 2020.
You asked the Plan to further pay for the services provided. The Plan denied your request. The Plan says the documentation failed to score toileting hygiene.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
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 further pay for the services provided.
Our reviewer found that toileting hygiene involves the ability to maintain perineal hygiene and the adjustment of clothes before and after voiding or having a bowel movement. Th enrollee was having difficulty parting her legs when on the toilet and maneuvering a hygiene device with tremors. The enrollee was requiring moderate assistance for toileting on March 2, 2020, and March 26, 2020. The available documentation is insufficient to support usual toileting hygiene, perineal hygiene, and the adjustment of clothes at supervision level. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to further pay for skilled nursing facility (SNF) services provided from March 20, 2020, to March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the out-of-network twelve (12) month rental of non-invasive home ventilator (CPT code E0466RR), the purchase of a heated humidifier (CPT code E0562NU), water chamber for humidifier (CPT code A7046NU x 1), full face mask (A7030NU x1), nasal interface used with PAP device (CPT code A7034NU x 1)], tubing (CPT code A7037NU x 1), no disposable filter (CPT code A7039NU X 12), oxygen tubing (CPT code A4616 x 1), and disposable filter (CPT code A7038NU X 12) to be provided from dates of service January 27, 2022, through January 26, 2023.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says there is no evidence that the enrollee has tried and failed continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or BIPAP with a back-up rate.
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 DME. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has COPD, but the records do not include an arterial blood gas, obtained while the enrollee is awake and stable, that documents carbon dioxide (CO2) retention. The enrollee already has BiPAP, but there is no documentation of compliance with its use. There is no documentation of BiPAP failure in the home setting. It appears BiPAP with AVAPS has not been tried. Medicare does not cover a home ventilator when used as BiPAP. If the enrollee is benefiting from BiPAP, there is no reason to use a ventilator in addition. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the out-of-network twelve (12) month rental of non-invasive home ventilator (CPT code E0466RR), the purchase of a heated humidifier (CPT code E0562NU), water chamber for humidifier (CPT code A7046NU x 1), full face mask (A7030NU x1), nasal interface used with PAP device (CPT code A7034NU x 1)], tubing (CPT code A7037NU x 1), no disposable filter (CPT code A7039NU X 12), oxygen tubing (CPT code A4616 x 1), and disposable filter (CPT code A7038NU X 12) to be provided from dates of service January 27, 2022, through January 26, 2023.