Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the prostate. 
 
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 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 CT scan is not medically necessary; however, no 
medical records were submitted to support this determination. The file shows that records were received by the 
Plan but these records were not made available to MAXIMUS. MAXIMUS requested these records, but a 
response was not received. Therefore, we decided that the Plan has to pre-approve a computed tomography 
(CT) scan of the prostate.  
 
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 physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like to continue seeing this 
provider. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
physician services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychotherapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON psychotherapy services. You say that the enrollee requires care 
from a Spanish-speaking provider and the requested provider speaks Spanish and has been helping the enrollee 
for years. The Plan denied your request. The Plan says this provider was removed from the plan's network due 
to questionable administrative practices and there are other Spanish-speaking clinicians available to provide 
this care. 
 
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 
the psychotherapy services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested consultation office visit. 
 
You asked the Plan to pre-approve the consultation office visit. The Plan denied your request. The Plan says 
you do not meet the internal criteria as stated in the original denial. The services are available locally, in-
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 the 
requested consultation office visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say 
that this device would restore function to the dysfunctional arm and the ability to perform activities of daily 
living. The Plan denied your request. The Plan says a review of the current medical literature indicates that this 
device is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary, and are experimental and investigational, are not covered.   
 
We looked at the file and Medicare rules. There is insufficient medical record information submitted to show 
this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by 
Medicare. The requested limb orthosis continues to be denied because of insufficient evidence of its 
effectiveness. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity 
range of motion assist device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan can approve E0651. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical record documents subjective lymphedema of the trunk without any objective description of 
the degree of truncal lymphedema. The enrollee does not have unique characteristics that would indicate the 
segmented pump over a standard pump. There is no documentation of a trial and failure of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unspecified adjunctive procedure (D9999). 
 
You asked the Plan to pre-approve the unspecified adjunctive procedure (D9999). You say that the enrollee 
needs dentures made from a heat injected substance. You say that the enrollee cannot afford the extra cost. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the 
unspecified adjunctive procedure (D9999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the 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 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 through the current outpatient setting with services or at an acute care 
hospital. 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that transfer to an LTACH would add no additional 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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for suspected aspiration following the 
performance of a pericardial window. The enrollee was intubated/ventilated and subsequently received a 
tracheotomy. The enrollee remains on vasopressors and a ventilator. It is unclear how much weaning has 
been/is currently being conducted. There is no evidence that the enrollee requires services that are not currently 
available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute 
services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing 
long term care needs. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19, influenza and a NSTEMI.  
The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services. 
 
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 for the enrollee.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that your needs can be met at a lower level of 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. The short-
term acute care hospital can provide for all of your present inpatient care needs and you are receiving an 
appropriate level of care in the present setting. Continued care in the short-term acute care hospital is 
appropriate until you are stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a 
sub-acute rehabilitation facility or a skilled nursing facility. Our physician reviewer found that your condition 
does not meet Medicare criteria for LTACH services. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says services are available in-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 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 
the medical services to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) and computed 
tomography (CT) services to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the out of network MRI and CT services. You say that you only have 6-8 
weeks to live and need these tests done as soon as possible. You say that you have seen this provider in the 
past, through your plan, and that they should be covered. The Plan denied your request. The Plan says the 
requested facility is not participating or in-network. The Plan says that they made several attempts to obtain 
medical records, but did not receive clinical information supporting the need to go to an out of network 
provider. 
 
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 
magnetic resonance imaging (MRI) and computed tomography (CT) services to be provided by an out of 
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Veltassa powder for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Veltassa powder for the 
enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit for the enrollee. 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not supported to treat the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Retacrit. Our reviewer says that 
Retacrit is not medically reasonable and necessary for the enrollee in this case. The enrollee has anemia 
associated with hypoplastic bone marrow with a differential diagnosis of aplastic anemia. She has iron 
deficiency and history of B12 deficiency anemia. The associated diagnoses are not among the FDA labeled 
indications. The requested use is not supported in any of the CMS approved compendia. There are no 
supporting citations in a PubMed search. The use is not listed as not indicated, not recommended or not 
supported in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for coverage of Retacrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Prednisone for the enrollee.  
 
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable pain pump. 
 
You asked the Plan to pre-approve the implantable pain pump. You say that you have degenerative disc disease 
and do not want another fusion. You say that the requested device is medically justified for treatment of your 
condition. The Plan denied your request. The Plan says the requested device is not medically necessary. The 
Plan says that the enrollee already has an implanted spinal cord stimulator. 
 
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 implantable pain pump. Our 
reviewer says that an implantable pain pump is not medically necessary. Our physician reviewer found the 
enrollee has chronic low back following spine surgery. She has a spinal cord stimulator in place and 
functioning but the patient is still having breakthrough pain. She has visited the emergency room several times 
for opiate pain relief and has had intra-thecal drug trials. The request is for intra-thecal pump placement. There 
is no literature supporting the use of both devices at the same time in a patient. 
 
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 implantable pain pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable pain pump.