Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approveOrthovisc.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary and the step therapy requirement is notmet.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 services are not medically necessary and the step therapy requirement is not met; however, no medical records were received with the case file. Without medical records, a determination based on medical necessity and use of prior medications cannot be supported.Therefore, we decided that the Plan has to pre-approveOrthovisc.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CPAP machine.You asked the Plan to pre-approvethe CPAP machine. You say that your CPAP was ruined during a power surge on January 15, 2021.The Plan denied your request. The Plan says your medical records do not show that a sleep study has recently been completed.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP machine have not been met. Your medical records do not show that a sleep study has recently been completed.Therefore, we decided that the Plan does not have to pre-approvethe CPAP machine.
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.

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 is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: 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. 
 
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 is no documentation provided necessitating admission to a LTACH. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. There are no services available 
at the LTACH that you require that are not available at the health care setting being offered by the health plan. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis 
and condition and are able to be furnished safely and effectively only on an inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a hip fracture after a fall. 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, in 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.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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay $50 charged for additional sterilization equipment and measures
provided in a dental setting on June 18, 2020 coded as D1999.
You asked the Plan to pay for these services. You say that you say that these services should be covered. The
Plan denied your request. The Plan says the dental services billed are not covered. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that dental code D1999 is not a covered dental code. The
Plan stays that the supplies or additional services charged by this dentist are not services covered under the
dental benefit.
The Plan is correct in this case. Medicare does not cover dental services. Medicare is not making exceptions for
any extra services or equipment provided for dental services due to Covid-19. While the Plan contract provided
supplemental dental benefits, the services and items charged in this case are not covered by the Plan and would
not be covered under any circumstances. Therefore, we decided that the Plan does not have to pay for
additional sterilization equipment and measures provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial upper 
denture (D5211). 
 
You asked the Plan to pre-approve the dental items. You say that the enrollee needs an upper denture. The Plan 
denied your request. The Plan says 1 upper denture is covered every 60 months. The Plan also says that the 
frequency limit has been exceeded. 
 
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 of 1 upper denture 
every 60 months has been exceeded. The record shows that the Plan paid for a complete upper denture that you 
received on June 20, 2016. Therefore, we decided that the Plan does not have to pre-approve a complete upper 
denture (D5110) and a partial upper denture (D5211).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission 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 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 that the complexity of the enrollees 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. 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 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fora diagnostic digital breast tomosynthesis and a diagnostic mammogram provided on July 31, 2020.You asked the Plan to waive the copayments fora diagnostic digital breast tomosynthesis and a diagnostic mammogram. You say that this was a preventative service and you should not be responsible for the charges.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 $10 copayment for most X-rays and ultrasounds.The medical records show that you received a diagnostic digital breast tomosynthesis on July 31, 2020. Therefore, you are responsible to pay the $10 copayment. The medical records show that you received a diagnostic mammogram onJuly 31, 2020. Therefore, you are responsible to pay the $10 copayment.The total amount you owe is: $20. You have been asked to pay the total copayment amount of $20 for a diagnostic digital breast tomosynthesis and a diagnostic mammogram. A diagnostic digital breast tomosynthesis and a diagnostic mammogram fall 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 copayments fora diagnostic digital breast tomosynthesis and a diagnostic mammogram provided on July 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 
You asked the Plan to pre-approve home health care services. You say that you need home health services 
because your catheter cannot be changed in an office. The Plan denied your request. The Plan says home health 
aide services are not covered. 
 
The Plan must follow Medicare rules. The rules say that THE services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health care services. Our 
reviewer says that the criteria for home health care has not been met. Our physician reviewer found the 
documentation does not support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary in order to improve your condition, perform a maintenance program to 
maintain your condition, or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. Furthermore, you are requesting a home health 
aide which is considered custodial 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 home health care services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health care services.
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.
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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) guidance for 
needle placement (77021). 
 
You asked the Plan to pre-approve the MRI guidance for needle placement. You say that this service is 
medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 the MRI guidance for needle 
placement. Our reviewer says that this service does not meet the guidelines for coverage. Our physician 
reviewer found the MRI may not be supported when a tissue sample taken for testing (biopsy) includes a 
detailed picture study of the member's breast. The member?s record shows that this situation applies to the 
member. Based on a review of the provided documentation, the member had a tissue biopsy. Therefore, the 
review has determined that the member does not meet the guidelines provided for coverage. 
 
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 MRI guidance for needle placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) guidance for needle 
placement (77021).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve the non-emergency taxi transportation. You say that you were not aware 
that a round trip was considered two rides. The Plan denied your request. The Plan says you have exhausted 
your benefit for additional routine health-related transportation trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the non-emergency taxi transportation (A0100).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrencia (J0129).You asked the Plan to pre-approveOrencia. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy requirements have 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 certainPart 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 Orencia. Our reviewer says that the criteria for coverage of Orencia have not been met. Our physician reviewer found the enrollee has not trialed Simponi Aria, Inflectra, or Remicade. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications orreason this medication was not considered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have not been met.Therefore, we decided that the Plan doesnot have to pre-approveOrencia (J0129)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity device (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the powered orthosis is considered experimental in this 
application. 
 
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 powered upper extremity device. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found literature indicates that The MyoPro orthosis is considered experimental, 
investigational, and unproven when used to help restore function to arms and hands paralyzed or weakened by 
stroke, brachial plexus injury, cerebral palsy, or any other neurological or neuromuscular disease or injury. 
There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes, 
or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis. 
 
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 powered upper extremity device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity device (L8702).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF 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 is able to ambulate more than 100 feet and tending to activities of daily living with minimal supervision. 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-approveadmission to a skilled nursing facility (SNF).