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

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says there is no indication 
the enrollee has had an osteoporosis-related fracture. The Plan also says that the enrollee has not tried and 
failed Zoledronic Acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not 
tried and failed the required drug. Our reviewer found that there is no indication that the Plan's required drug 
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also 
found that there is no documentation that the enrollee has a history of an osteoporosis related fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you thought that your copayment 
would only be $40. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for basic radiological services provided in an outpatient hospital facility.  
 
You received an ultrasound at an outpatient hospital facility. Therefore, you are 
responsible to pay the $100 copayment.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the leg (73721). 
 
You asked the Plan to pre-approve MRI of the leg. You say that this requested MRI is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the 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 MRI of the leg. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the medical records do not clearly show 
that the patient has tried and failed home exercise or physical therapy for at least six weeks and the previous 
testing was not suggestive of radiculopathy. Therefore, without sufficient support made for this request, the 
right leg (hip) MRI will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the leg have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the magnetic resonance imaging (MRI) of the leg (73721).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says there are 
no skilled needs beyond intravenous antibiotics. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
Continued SNF services beyond February 11, 2021, were 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 continued services. Our physician reviewer found that from a nursing 
perspective, the enrollee received oral and intravenous medications, had stable vital signs, and her lungs were 
clear. There are identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a 
supervision to modified independent level with functional mobility. She required varying assist with activities 
of daily living. There are no identifiable skilled therapy service needs. The enrollee does require skilled 
services on a daily basis. However, she does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 24, 2019. 
 
You asked the Plan to pay for the services provided. You say that you depend on the facility for timely 
notification of the enrollee's insurance coverage. The Plan denied your request. The Plan says the claim was 
received past the allowed timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until September 18, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on July 24, 2019.
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 clinical information provided supports the need 
for care in an IRF. You say that you need more therapy than what you are currently getting. The Plan denied 
your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 hip replacement surgery and was discharged to a skilled nursing facility where physical and 
occupational services are provided. The enrollee's medical conditions are stable. There are no medical needs 
requiring inpatient admission. 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 documents a need for physical and 
occupational therapy, it does not document 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: 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 SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission 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 above 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required minimal to contact 
guard assistance with functional mobility including walking to 5 feet with a rolling walker. The documentation 
does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled 
professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a 
daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a 
SNF 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 SNF admission 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Guide test strips. 
 
You asked the Plan to pre-approve Accu-Chek Guide test strips. You say that the enrollee already has an Accu-
Chek meter. The Plan denied your request. The Plan says the requested test strips are not formulary. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those 
preferred brands and manufacturers, as long as the above conditions are met. 
 
We looked at the file and Medicare rules. The requested test strips are not the Plan's preferred brand. The 
submitted documentation does not include any medical reason that the Plan's preferred test strips cannot meet 
the enrollee's needs. Based on this information, we decided that Medicare rules for coverage of Accu-Chek 
Guide test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-
Chek Guide test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says you do not have 
elective out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
chemotherapy services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on September 2, 2020.
You asked the Plan to pay for out of network providers. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. Maximus overturned the Plans denial administratively because a plan contract had not been submitted with the appeal for review. The Plan requested a reopen and provided the required contract information.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office visit services provided to the enrollee on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve estradiol. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve estradiol.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings identified with code 
A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need compression stockings 
for your varicose veins. The Plan denied your request. The Plan says these dressings are non-covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
non-covered 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 gradient 
compression stockings identified with code A6530.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
care in a SNF. The Plan denied your request. The Plan says the enrollee does not meet the criteria for approval 
of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not support 
that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
is required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The 
enrollee does not have complex wound care or other needs that requires a SNF stay. The enrollee's functional 
level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. Skilled 
services are not needed on a daily basis or as practical matter 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced leg pump device (E0652, E0667) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an advanced leg pump device to be provided by an OON provider. You say 
that the items are necessary. The Plan denied your request. The Plan says the items are able to be provided by 
an in-network provider. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an advanced leg pump device (E0652, E0667) to be provided by an out of network (OON) provider.
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of an 
IRF admission and that the enrollee can safely receive the services needed in another 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 above. 
 
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 nonsurgical management of a periprosthetic femur fracture after a fall. The enrollee's medical 
conditions are stable. There are no medical needs requiring inpatient admission. 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 
documents a need for physical and occupational therapy, it does not document 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 a stroke. The enrollee's medical conditions are stable. There are no medical needs requiring 
inpatient admission. 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 documents a need for physical and occupational 
therapy, it does not document 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevations system. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the seat 
elevator does not serve a primary medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevations system.