Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMs device.

You asked the Plan to pre-approve the CardioMEMs device. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says that studies do not show that this device improves long term outcomes and is considered investigational.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 CardioMEMs device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found CardioMEMs device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. Given the severe symptoms of recurrent congestive heart failure (CHF) which appears very sensitive to volume loading conditions, the complexity of the medical regimen, pre-renal azotemia from excessive diuresis and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMs device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one.

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 CardioMEMs device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMs device.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 25, 2021.

You asked the Plan to pre-approve the continued SNF stay. You say that it is felt that SNF care is needed. The Plan denied your request. The Plan says the enrollee does not require daily skilled 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a male with a medical history that includes mental health changes, urinary tract infection, hypertension, coronary artery disease, polymyalgia rheumatica, and traumatic brain injury. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for a C. difficile infection. Regarding rehabilitation services, the beneficiary received physical and occupational therapy. The beneficiary was at a supervision to contact guard/minimal assist level with functional mobility including gait to 100 feet. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 25, 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. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 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 enrollee'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 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 a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee was admitted for syncope and non-surgical management of a humerus
fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation
needs. While the documentation does support a need for physical and/or occupational therapy, there is no
documented need for an intensive, multi-disciplinary rehabilitation program. Therefore, the enrollee does not meet 
criteria for the requested admission.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. Physical therapy three times per week is recommended in the provided records. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint (64451).

You asked the Plan to pre-approve RFA of the SI joint. You say that the requested RFA of the SI joint is medically necessary. The Plan denied your request. The Plan says the requested RFA of the SI joint 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 RFA of the SI joint. Our reviewer says that the requested RFA of the SI joint is not medically necessary. Our physician reviewer found the enrollee has sacroilitis demonstrated by history and physical exam findings. She is taking Norco for pain and also has used a TENS unit. She underwent Sacral Cluneal nerve blocks with 80% pain relief for the length of the local anesthetic. The request is for RFA of these nerves. This is considered an experimental/investigational procedure. Therefore, the request is deemed 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint (64451).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar spine MRI.
You asked the Plan to pre-approve a lumbar spine MRI. You say that the requested lumbar spine MRI is medically necessary. The Plan denied your request. The Plan says the requested lumbar spine MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 lumbar spine MRI. Our reviewer says that the requested lumbar spine MRI is not medically necessary. Our physician reviewer found the record indicates that the enrollee developed back spasms after lifting heavy items two weeks previously. The record indicates that on the day of the evaluation the enrollee was asymptomatic there is a normal musculoskeletal and neurologic examination. The record indicates an X-ray demonstrated mild to moderate degenerative disc disease but no fracture. The enrollee has not completed a course of conservative therapy including physical therapy. The record does not indicate the presence of neurologic compromise. The record indicates that the enrollee requested testing. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 lumbar spine MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar spine MRI.
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 the documentation provided, 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 hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility, home health services, outpatient therapy).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the documentation does not support a need for a therapy program consisting of at least 3 hours of therapy per day for at least 5 days per week with frequent physician oversight and an
interdisciplinary approach to rehabilitation care. The enrollee will not be able to tolerate the intensity of IRF level of therapy. While the enrollee may benefit from physical and occupational therapy, the enrollee's therapy needs can be met in a lower intensity setting such as home health or skilled nursing 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stab phlebectomy of varicose veins (37765).
You asked the Plan to pre-approve Stab phlebectomy of varicose veins (37765). You say that the requested Stab phlebectomy of varicose veins (37765) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Stab phlebectomy of varicose veins (37765).
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 Stab phlebectomy of varicose veins (37765). Our reviewer says that the enrollee does not meet criteria for the requested Stab phlebectomy of varicose veins (37765). Our physician reviewer found the record indicates that the saphenous vein reflux has been treated. The record does not indicate that the varicosities recommended for treatment are greater than 4 mm in diameter. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Stab phlebectomy of varicose veins (37765) have not been met. Therefore, we decided that the Plan does not have to pre-approve Stab phlebectomy of varicose veins (37765).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you will be unsafe at home and require rehabilitation. You state you suffer from acute hypoxemic respiratory failure. You state that if you go home your health could be in danger. The Plan denied your request. The Plan says the stay is not medically necessary.
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 based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. There is no detailed documentation indicating a requirement for skilled therapy services. There is no documentation of a need for daily skilled services is provided. You do not require the services on an inpatient basis, only in a SNF setting. Records do not document that services in a long-term care facility on a part time basis or in the home or an assisted living facility with home health care are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block (64454).
You asked the Plan to pre-approve a genicular nerve block (64454). You say that the requested genicular nerve block (64454) is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve block (64454) 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 a genicular nerve block (64454). Our reviewer says that the requested genicular nerve block (64454) is not medically necessary. Our physician reviewer found the review indicates that the enrollee is diagnosed with right knee pain. She is status post right tibial plateau fracture (2020) which required surgery. She has been treated with medical therapy and physical therapy. Her provider has recommended a genicular nerve block. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment
following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block of the right knee 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 a genicular nerve block (64454) have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block (64454).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you continue to receive acute care services, and these have not been denied. The medical records do not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.