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

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to LTACH is the most 
appropriate level of care for this enrollee. The Plan denied your request. The Plan says the LTACH admission 
is not medically necessary, and does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require any services at the LTACH that are not already 
available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Our physician reviewer also found 
that transfer to a lower level of care may be considered when the enrollee is more stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zirabev, Liposomal Doxorubicin, and Granisetron. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says you will 
not be using Zirabev or Doxorubicin as monotherapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the requested drugs. Our physician 
reviewer found that you have metastatic endometrial cancer. The requested use of the rugs is not FDA-
approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Second line treatment is with monotherapy 
or now pembrolizumab, with or without lenvatinib depending on MSI/MMR status. The documentation does 
not support that the requested drugs are safe and effective, and otherwise reasonable and 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 the requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zirabev, Liposomal Doxorubicin, and Granisetron.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan with CT. 
 
You asked the Plan to pre-approve a PET scan with CT. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the requested 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 case file submitted to Maximus was largely incomplete. The 2020 Evidence 
of Coverage, Initial authorization request, Plan's initial denial, Reconsideration request, plan's reconsideration 
determination, and medical records used in supporting the denial were not provided. Maximus requested 
additional information on two different occasions with no response. Therefore, we decided that the Plan has to 
pre-approve a PET scan with CT.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic Resonance Spectroscopy (76390). 
 
You asked the Plan to pre-approve a Magnetic Resonance Spectroscopy (76390). You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested Magnetic 
Resonance Spectroscopy is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare considers a Magnetic Resonance Spectroscopy (MRS) an 
investigational procedure and issued a national noncoverage determination for all indications of MRS. Based 
on this information, we decided that Medicare rules for coverage of a Magnetic Resonance Spectroscopy 
(76390) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Magnetic 
Resonance Spectroscopy (76390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they 
are medically reasonable and necessary and replace a blood glucose monitor. 
 
We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only 
when a patient has been performing four or more blood glucose tests every day and is insulin-treated with at 
least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion 
(CSII) pump. The file does not show that the enrollee injects insulin at least three or more times per day. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy and pin retention for tooth #6. 
 
You asked the Plan to pre-approve the requested services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says the requested services are 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic 
therapy and pin retention for tooth #6.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone scan. 
 
You asked the Plan to pre-approve a bone scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that original Medicare covers the routine costs of 
qualifying clinical trials for all Medicare enrollees. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a bone scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
bone scan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested outpatient therapy services. 
 
You asked the Plan to pre-approve the outpatient therapy services. The Plan denied your request. The Plan says 
that the Plan covers care from non-participating providers under limited circumstances such as during 
emergency care delivered in an emergency room in the United States or its territories or in the Plan's service 
area when the network of doctors and other health care professionals, medical groups, hospitals, and other 
health care facilities cannot provide the requested 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 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 outpatient therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Floweraminoflo injections. 
 
You asked the Plan to pre-approve Floweraminoflo injections. You say that the enrollee has severe knee pain 
and inflammation. The Plan denied your request. The Plan says there is inadequate evidence to support the 
clinical effectiveness. 
 
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 Floweraminoflo injections. Our 
physician reviewer found that you have bilateral knee pain from a fall off a 10-foot ladder. Your pain is rated 8 
on a scale of 10 and is constant. You have had a positive MRI that shows severe damage to the right knee. The 
left knee has no imaging, however, it hurts him as much as the right. You have tried over the counter drugs, 
opiates, therapy, steroid injections, and nothing has proved beneficial. Peer reviewed literature considers 
FLOWERFLO (Floweraminoflo) treatments experimental and investigational because there is inadequate 
evidence in the peer-reviewed medical literature to support their clinical effectiveness. The review has 
determined that the requested injection is not safe and effective to treat your condition. Therefore, the requested 
injection is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Floweraminoflo injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Floweraminoflo injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination tilt and recline power seating system. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a combination tilt and recline power seating 
system are covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the seating and mobility evaluation 
dated May 21, 2020 indicates that the enrollee is independent in ability to perform a weight shift while seated. 
The documentation does not indicate that the enrollee is at high risk for development of a pressure ulcer and is 
unable to perform a functional weight shift, utilizes intermittent catheterization for bladder management, and is 
unable to independently transfer from the wheelchair to a bed. The power seating is not required to manage or 
increase tone or spasticity. The services are not reasonable or medically necessary. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a combination tilt and recline power seating system.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient psychiatric services from August 25, 2020 
forward. 
 
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 services are not medically necessary; however, there are 
no medical records for your inpatient admission beginning August 18, 2020. Without medical records, a 
determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-
approve continued inpatient psychiatric services from August 25, 2020 forward.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture.
You asked the Plan to pre-approve the complete upper and lower denture. You say that the dentures are ill fitting and are causing pain and sores on both sides of your mouth. You say that your dental benefit should be reinstated. The Plan denied your request. The Plan says your benefit has been exhausted for the 2020 plan year.
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, you also have a maximum benefit of one upper complete denture and one lower complete denture every 5 years. The Plan paid for one upper complete denture and one lower complete denture provided on December 19, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture.
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 enrollee clearly exceeds the CMS 
established defining criteria for a medically appropriate LTACH admission. The Plan denied your request. The 
Plan says the enrollee does not meet the Medicare guideline requirements. 
 
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 based on the documentation provided, the enrollee appears to be improving, but 
still requires additional short-term acute care services to diagnose the source of rising leukocytosis. The 
enrollee does not require any services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
Transfer to an appropriate location may be considered when the enrollee is more stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services required exceed the clinical 
capabilities of all lower levels of care. The Plan denied your request. The Plan says the enrollee's neurologic 
status is unstable, and he has not completed the full course of care in the hospital. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital for cardiac surgery which was 
complicated by respiratory failure due to pulmonary edema. He was diagnosed with metabolic encephalopathy 
and treated with mechanical ventilation and chest tubes. He currently is still unstable with delirium, and still 
requires aggressive physical therapy, tube feeds, ventilation weaning, and close monitoring. The enrollee does 
not require any services at the LTACH that are not already available at the current facility. Therefore, this 
request for LTACH services is 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ambrisentan. 
 
You asked the Plan to pre-approve Ambrisentan. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
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 Ambrisentan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to transfer to begin inpatient 
rehabilitation then return to home. The Plan denied your request. The Plan says services can safely be given in 
a lower level of care. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is not 
expected to fully benefit from the intensity of services of an IRF. 
 
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 physician reviewer found 
that the enrollee was admitted for surgery for a hernia. Post-operative complications included new onset atrial 
fibrillation and anemia. All medical problems are now stable. 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. 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. While the 
record supports a need for physical and occupational therapy, it does not support a need for an intensive 
rehabilitation therapy 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-approve acute inpatient rehabilitation facility (IRF) admission and services.