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

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan states the services the enrollee needs could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.  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 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 at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Procrit (Q5106).  You asked the Plan to pre-approve Procrit. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says requested drug is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Procrit. Our reviewer says that the request for Procrit is not medically necessary. Our physician reviewer found the provided records do not include documentation of the enrollee's iron stores as, if low, they need to be made replete before the initiation of therapy. Therefore, the reviewer found that the request for Procrit 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 Procrit have not been met. Specifically, the file does not include documentation of the enrollee's iron stores. Therefore, we decided that the Plan does not have to pre-approve Procrit (Q5106).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 would like reconsideration because the requested LTACH services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the LTACH services.  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 there are no services at the LTACH that the member requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed and the member is more stable.     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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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 reviewcatheter placement. You were discharged home and are now medically stable with no complex nursing or rehabilitation needs. Your current level of function does not require an intensive therapy program in an IRF. The IRF services are not reasonable or 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 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 reconsideration because the requested IRF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the IRF 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 IRF admission is not medically necessary based on lack of medical complexity, and rehab nursing needs and current functional level. The documentation does not support the necessity for admission to an IRF. The enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as continuing at home with therapies.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home infusion of Bivigam.  You asked the Plan to pre-approve the home infusion of Bivigam.. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the home infusion services.  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 home infusion of Bivigam.. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have a covered condition for the home infusion.   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 home infusion of Bivigam. have not been met. Therefore, we decided that the Plan does not have to pre-approve the home infusion of Bivigam.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hyalgan.  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 covered.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 stroke and discharged home on February 4, 2022. 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 she has 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 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 inpatient behavioral admission from February 16, 2022, forwards.  You asked the Plan to pre-approve inpatient behavioral admission. You say that the enrollee is not safe to discharge. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient behavioral admission. Our reviewer says that the inpatient behavioral admission is not medically necessary. Our physician reviewer found the provided records indicate that it was not expected the enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The reviewer found that the enrollee does not meet the criteria for treatment in an acute inpatient behavioral health treatment beyond February 15, 2022 and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral admission have not been met. Specifically, the file indicates that the enrollee was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral admission from February 16, 2022, forwards.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee does not require an intensive therapy services 3 hours a day.  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. The enrollee was admitted for urosepsis and surgical repair of an ankle fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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. Medically necessary care can be provided in a different level of care. 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve vascular embolization or occlusion (37242), selective catheter placement (36245), aortography (75625) and angiography (75710 and 75716).  You asked the Plan to pre-approve the vascular embolization, selective catheter placement, aortography and angiography. You say that you would like reconsideration because the requested services are medically necessary. The Plan denied your request. The Plan says the requested services are not related to the approved prostate artery embolization and are therefore 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 the vascular embolization, selective catheter placement, aortography and angiography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found it should be made clear that the health plan has indeed approved the prostate artery embolization and related procedure codes.  Billing codes not approved include a code for embolization of a separate vascular structure (other than of the prostate which has been approved), and codes for diagnostic angiography of the aorta and extremities.  There is no documentation provided in the medical record suggesting the patient requires peripheral vascular angiography or embolization of a separate vascular structure in addition to the prostate.  There is also a code for a first order selective catheterization that has not been approved.  However, higher level codes that would be required to embolize the prostatic artery already have been approved and therefore coding of a lower order vessel is unnecessary and not billable.  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 vascular embolization, selective catheter placement, aortography and angiography have not been met. Therefore, we decided that the Plan does not have to pre-approve vascular embolization or occlusion (37242), selective catheter placement (36245), aortography (75625) and angiography (75710 and 75716).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that the dressings are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the dressings.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.