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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 17, 
2020, to September 19, 2020. 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care provided was 
medically necessary. The Plan denied your request. The Plan says inpatient care was not necessary and care 
could have been provided at lower level. 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient is a 61-year-old female with dizziness who presented to the emergency 
department. She was diagnosed with anemia, acute on chronic kidney injury, and dehydration, and admitted to 
the hospital. Based on the required and planned treatments, observation would have been appropriate to 
monitor and treat with fluids and Venofer prior to discharging for outpatient follow-up. Therefore, it was not 
expected that the patient would require hospital care that would likely cross two midnights. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided September 17, 2020, to September 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pay forelectrical stimulator supplies (A4595) provided to the enrollee on March 26, 2020.You asked the Plan to pay forthese DME supplies. You say that this claim should be paid.The Plan denied your request. The Plan says these types of supplies cannot be ordered via a Telehealth visit. Maximus overturned the denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.The Plan is correct in this case. The Plan must follow Medicare rules. Medicare covers specific services during telehealth visits. This type of durable medical equipment or equipment supply is not eligible to be ordered during atelehealth visit. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay forelectrical stimulator supplies (A4595) provided to the enrollee on March 26, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Monovisc.

You asked the Plan to pre-approve these services. You say that the injection should be covered. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the Monovisc injection is not medically necessary; however, no medical records were submitted. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve Monovisc. 

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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are on a ventilator and require 
admission to a LTACH to improve your health. The Plan denied your request. The Plan says that your medical 
needs are being met in the current acute setting. The LTACH would add no additional services. With additional 
time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be 
determined. 
 
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 that you appear to be gradually improving but require additional short term acute care 
services which can safely be administered at the current facility. You do not require services at the LTACH that 
are not already available at the current facility. Therefore, this request for LTACH services will be considered 
not medically necessary at this time. Transfer to a lower level of care may be considered soon when appropriate 
and 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that this service is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria has not been met. 
 
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 Entyvio. Our reviewer says that step 
therapy criteria has not been met. Our physician reviewer found the enrollee is a 73-year-old female with 
inflammatory bowel disease-Crohn's disease. The Plan requires a trial of Remicade or Inflectra and Stelara 
before they will approve the requested drug. In this case, the patient has not tried and failed the required 
drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure cuff (A4670). 
 
You asked the Plan to pre-approve the automatic blood pressure cuff. You say that the blood pressure cuff is 
medically necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure cuff (A4670).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay for a hearing aid check provided on August 11, 2020.
You asked the Plan to pay for a hearing aid check. You say that this hearing aid check should be covered. The Plan denied your request. The Plan says your hearing aids are over a year old. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information to show your hearing aids are well over a year old at the time of service.
The Plan is correct in this case. Medicare does not pay for hearing aids or related services. The Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing checks twice within the first 12 months of purchase. The Plan has provided documentation that these hearing aids are over 12 months old on the date they were serviced. Therefore, we decided that the Plan does not have to pay for a hearing aid check provided on August 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis, 500mg every 6 weeks. 
 
You asked the Plan to pre-approve the increased dose of Renflexis. You say that the increase in dosage of 
Renflexis is medically necessary. The Plan denied your request. The Plan says the requested dosage 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 the increased dose of Renflexis. Our 
reviewer says that the increased dosage is not medically necessary. Our physician reviewer found 
documentation does not note why such an increase is medically necessary in this enrollee.  There is no 
evidence of an increase in symptoms or an incomplete or decreasing response to the prior dose. 
 
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 increased dose of Renflexis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Renflexis, 500mg every 6 weeks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this should be paid for. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-intravenous conscious sedation (D9248). 
 
You asked the Plan to pre-approve the sedation. You say that it as been over 35 years you've seen a dentist. 
You need a lot of work done which will take time. you are requesting sedation to be comfortable during the 
procedure. The Plan denied your request. The Plan says this service is not listed under the plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The health plan contract 
specifically says on page 4-63 that any service not listed is not covered.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve non-
intravenous conscious sedation (D9248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that the denture payment for 2017 was to be 
recovered, allowing the enrollee to be eligible for new dentures again. The Plan denied your request. The Plan 
says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been 
reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit for dentures has 
been reached. The record shows that the Plan paid for the dentures you received on November 15, 2017. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says 
this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture (D5226).
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Eylea 2 MG/0.05 ML Syringe. 
 
You asked the Plan to pre-approve Eylea 2 MG/0.05 ML Syringe. You say that the medication is necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
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 Eylea 2 MG/0.05 ML Syringe. Our 
reviewer says that the medication is medically necessary. Our physician reviewer found step therapy may only 
be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving 
the affected medication. In this case, the member has had a previous Eylea injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea 2 MG/0.05 ML Syringe have been met. Therefore, we decided that the 
Plan has to pre-approve Eylea 2 MG/0.05 ML Syringe.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that you feel that the services are 
medically necessary and should be covered by the plan. The Plan denied your request. The Plan says the 
procedure 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. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
request for an endocrinologist is available within your health plan network. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic mattress. 
 
You asked the Plan to pre-approve these services. You say that the mattress will aid in recovery. The Plan 
denied your request. The Plan says the services are not covered. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic mattress.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for vision services provided on August 6, 2020. 
 
You asked the Plan to pay for this service. You say that the refraction services should be covered. The Plan 
denied your request. The Plan says that these services are not covered under the Plan contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. The Plan did not provide and Explanation of Benefits or medical 
records to show the eye refraction services provided. The Plan submitted records for a service not in dispute. 
Therefore, we decided that the Plan has to pay for vision services provided on August 6, 2020.  
 
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.