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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee remains at high risk for falls and 
requires an intensive acute rehabilitation program. The Plan denied your request. The Plan says the denial of 
authorization for IRF care 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 enrollee is medically stable and does not need rehabilitation physician supervision 3 times per week. While the enrollee would benefit from physical and occupational therapy, the 
enrollee's needs can be safely met in an alternate low-intensity setting such as 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: 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 disagree with the denial. The Plan denied your 
request. The Plan says the 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for a fall and closed head injury and was discharged home on July 4, 2022. He is now medically stable 
with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not strong enough to be home. The Plan 
denied your request. The Plan says your care can be rendered in an alternate setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute hospital for difficulty breathing and palpitations. You have stabilized 
medically. The most recent therapy notes indicate that you are able to ambulate household distances with a 
wheeled walker and can accomplish transfers with minimal assistance.  The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation 
therapy program. 
 
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 skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says authorization denied because the SNF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of service, such as at home with supervision and home health 
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 care. Our reviewer says that 
the SNF care is not medically necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. Based on the medical records provided there is no 
documentation that daily skilled services are required. Although records document the enrollee is very limited 
functionally, provided records do not document a significant decline in the enrollees functional status 
compared to her recent baseline to necessitate daily inpatient skilled therapy services. As a practical matter, the 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. Based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document 
that services in the home with home health care or in a long-term care facility on a part time basis 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile heart monitoring device. 
 
You asked the Plan to pre-approve the requested services. You say that you will continue to have irregular 
heart rates without the device. The Plan denied your request. The Plan says the request 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.  
 
The file shows that a mobile cardiac outpatient telemetry (MCOT) monitor was requested. 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 requested services. Our physician reviewer found 
that you have frequent, daily symptoms. There is no supportive evidence that the ordering practitioner 
documented any standard, non-MCOT, ambulatory electrocardiogram (ECG) monitoring. In summary, there is 
insufficient documentation to support the medical necessity for an MCOT monitor in your clinical 
management. 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a mobile heart monitoring device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care to be 
provided by a network facility. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that you have been making good 
progress but would like to stay longer to reach maximum mobility. The Plan denied your request. The Plan 
says authorization because the SNF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as assisted living, long-term care, or home with family.  
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 continuation of SNF care. Our 
reviewer says that the continuation of SNF care is not medically necessary. Our physician reviewer found there 
are no identifiable skilled nursing service needs that require skilled nursing services, including the specialized 
skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide 
medically necessary and reasonable treatment. There are identifiable skilled therapy service needs that require 
skilled therapy services, including the specialized skill, knowledge and judgment of a qualified therapist 
required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical 
records provided there is no documentation that further daily skilled services are required. You are walking 
household distances with a two wheeled walker on even and uneven surfaces and negotiating 15 steps with 
stand-by assistance and voice instructions and is supervision for transfers. Provided records do not document a 
significant decline in your functional status to necessitate further daily inpatient skilled therapy services. Based 
on the medical records provided there is no documentation that you require the services on an inpatient basis, 
only in a skilled nursing facility setting. Records do not document that services in the home with home health 
care or in a long-term care facility on a part time basis 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care to be provided by a 
network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal vertebral body decompression review (63090), 
removal vertebral body decompression, additional level review (63091x2), lumbar fusion review (22558x1), 
lumbar decompression review (63056), lumbar fusion review (22612), biomechanical device review 
(22854x2), bone graft review (20930x2), graft spine defect review (63710x2) and bone marrow graft harvest 
review (20939). 
 
You asked the Plan to pre-approve lumbar fusion. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says services requested do not meet medical necessity. 
 
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 lumbar fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has had the pain for 8-9 months and is status post laminectomy L4-5 on 12/6/2019. 
There is no documentation of conservative measures to include physical therapy (PT) for 3 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal vertebral body decompression review (63090), removal vertebral body 
decompression, additional level review (63091x2), lumbar fusion review (22558x1), lumbar decompression 
review (63056), lumbar fusion review (22612), biomechanical device review (22854x2), bone graft review 
(20930x2), graft spine defect review (63710x2) and bone marrow graft harvest review (20939).
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 disagree with the denial and want a 
reconsideration. The Plan denied your request. The Plan says the service requested is not supported based on 
the records we received. 
 
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. The patient was admitted for weakness and falls. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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: 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 disagree with the denial. The Plan denied your 
request. The Plan says the 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 medically necessary. Our physician reviewer found you were admitted to the hospital 
for surgery after a fall. You are now medically stable with 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 enrollee can be transferred to 
LTACH level of care for continuation of care of complex medical needs that require ongoing acute care. The 
Plan denied your request. The Plan says based on the review of medical records provided, the complexity of the 
enrollee's needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care and ventilator weaning. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 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: 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 you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 tolerating gradual weaning; however, does not have a 
stable feeding source yet and requires additional acute care services that can be safely administered at the 
current facility until the enrollee is more stable and appropriate for transfer. 
 
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: 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 disagree with the denial. The Plan denied your 
request. The Plan says the 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with cellulitis and infection of left knee surgical site. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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.