Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endovascular revascularization.  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 percutaneous transluminal angioplasty (PTA) is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records have conflicting information regarding the enrollee's symptoms, with one area noting that he has some pain when walking and another where he denies leg pain. In no part of the evaluation is there any suggestion of lifestyle limiting symptoms or signs of limb threat. He has documented palpable pedal pulses and normal noninvasive arterial studies within the same year. There is no rationale provided as to why lower extremity angiography is even being considered. The services are not 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 endovascular revascularization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Freestyle lite test strips (CPT code A4253).  You asked the Plan to pre-approve the items. You say that you need a product not listed on the plan's list of covered drugs. The Plan denied your request. The Plan says the criteria have not been met. The Plan states you must try and fail all preferred blood glucose testing products that are covered by your plan.  The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the items. Our physician reviewer found the health plan's denial should be upheld. You are noted to have type 2 diabetes, for which you reportedly do home blood glucose testing. Your blood glucose and what brand of testing supplies you use is not noted. There is no documentation that you have tried and failed the health plan's preferred brand of diabetic testing supplies. As such, the requested for Freestyle Lite testing strips is not shown to be medically necessary or reasonable.  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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle lite test strips (CPT code A4253).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued admission in a skilled nursing facility (SNF).  You asked the Plan to pre-approve continued admission in a SNF. You say that the requested continued admission in a SNF is medically necessary. The Plan denied your request. The Plan says the requested continued admission in a SNF does not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued admission in a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled therapy needs. You are ambulating more than 100 feet. 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 continued admission in a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission in a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be critically ill with low chance of recovery and should require only short-term additional acute care hospital services that can safely be received at the current facility. There are no services at LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed and a more appropriate lower level of care is arranged.   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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs or skilled therapy needs. The enrollee is not shown to have an acute decline in function or to be able to participate in the rigors of daily skilled therapy. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and intermittent, can, as a practical matter, 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. All services that would be provided in the LTACH are being provided in the current acute
care setting which is already approved. Therefore, the requested LTACH services are not medically necessary,
reasonable, or appropriate for the diagnosis and condition of the enrollee at this time. The enrollee can remain
in the current acute care location until such time no further acute level care is needed.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be more stable and improving and requires only short-term
additional acute care services that can be safely administered at the current facility. The enrollee does not
require services at the LTACH that are not already available and covered at the current facility. Transfer to the
LTACH is not medically necessary as it would not be clinically advantageous at this time. Transfer to a lower
level of care may be considered when treatment has completed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you live alone and have a drainage tube for your lungs. You said that you cannot take care of yourself because you need help with these tubes. The Plan denied your request. The Plan says that you do not meet criteria for SNF 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 SNF care. Our reviewer says that SNF care is medically necessary for you. Our physician reviewer found you have documented skilled nursing needs. You have a newly placed chest catheter, which needs to be tended to daily, and for which you and/or caregiver needs education. You do not have documented skilled therapy needs. You require a low level of supervision for mobility and appear unable to participate in the rigors of daily skilled therapy. A less intensive therapy (i.e. intermittent, nursing) is not unreasonable. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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 IRF care is medically necessary. The Plan denied your request. The Plan says it is not reasonable to expect that you will be able to fully benefit from the intensity of services at 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. You were admitted for encephalopathy, pneumonia, and respiratory failure and your medical problems are stable. There are no complex nursing or rehabilitation needs. The doctor says 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to have a poor prognosis, not likely a good candidate for weaning and should require additional short-term acute care hospital services that can safely be received at the current facility. There are no services at LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and longer-term placement has been arranged.   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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health services.  You asked the Plan to pre-approve additional home health services. You say that additional home health services are medically necessary. The Plan denied your request. The Plan says you have already received home health and your goals were met. You were discharged from home health and no further home health care is warranted.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 additional home health services. Our reviewer says that you no not meet criteria for additional home health services Our physician reviewer found you do not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy, etc.).  You do not have documented skilled therapy needs.  Skilled services are not shown to be medically necessary to treat an acute illness or injury.  Your care needs appear to be custodial and manageable by your family and caregivers.  The requested home health services are not medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health 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 inpatient rehab is medically necessary. The Plan denied your request. The Plan says your care is routine in nature and you could not tolerate aggressive therapy. The Plan says that you do not need a team of providers and you can be managed 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 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 respiratory failure and pneumonia and your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification (CPT code E1220), for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that you are requesting the authorization to be approved. The Plan denied your request. The Plan says the enrollee's records do not show that they have problems finishing one or more (MRADLs) in their home, or that they cannot use a cane or walker to complete their MRADLs. The Plan states the enrollee's records also do not show that they cannot balance or use a scooter safely, or that their home provides enough room for use of the wheelchair.
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 wheelchair. physician reviewer found the power wheelchair is needed for, "increasing her functionality for activities of daily living (ADL), reducing risk of falls, ulcers and major complications." Records are not clear that this patient has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Records document that the enrollee is a bilateral lower extremity amputee with no indication that they use lower extremity prostheses for mobility. The enrollee is reported to be wheelchair dependent. Even though provided records do not explicitly address a cane or walker, given his bilateral amputee status it appears clear that they cannot be adequately helped by use of a cane or walker. Based on the medical records provided there is no clear documentation that the enrollee can safely operate a power mobility device. Based on the medical records provided there is no clear documentation that the enrollee's home provides adequate access, maneuvering space and surfaces for the operation of a power wheelchair. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification (CPT code E1220), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and
64629), for the enrollee.
You asked the Plan to pre-approve the services. You say that the intracept procedure is medically necessary
and supported by strong science. You state that you would like to perform this procedure at L3, L4 and L5
vertebral bodies to provide relief for the enrollee. The Plan denied your request. The Plan says there is little
evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain.
The Plan states it is not an accepted standard of medical practice for the diagnosis or treatment of back pain.
The Plan states it is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the intracept procedure 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629), for the enrollee.