Persius/hicric huggingface dataset:
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 enrollee requires an acute rehab level of care in order to promote proper wound care, care for multiple medical conditions, and to increase his safety and independence in order to return home with his wife. The appellant says that the enrollee would benefit from daily physician oversight, wound care, and infectious disease oversight due to his complicated wounds, recent amputations and multiple medical comorbidities. You say that the enrollee requires intensive multidisciplinary therapy in order to safely complete self-care and mobility while maintaining weight bearing precautions. You say that, without acute rehab level of care the enrollee is at risk of falls with injury, sepsis,further amputations, worsening AKI, uncontrolled diabetes, and cardiac complications.The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF care. The Plan says that the enrollee can safely receive the services needed in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the medical 
necessity of SNF care. The Plan denied your request. The Plan says the clinical information does not show that 
SNF care is 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not support 
that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
is required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The 
enrollee does not have complex wound care or other skilled nursing needs that require a SNF stay. The 
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 27, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forbattery. You say that the provider told you that you would be reimbursed for this item, and you were not informed that prior authorization was required for using an out-of-network provider.The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is out-of-network with the Plan and authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 27, 2020, by an out-of-network (OON) provider.Your complaint regarding not being told about the authorization requirements for this item is considered to be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is not a surgical candidate. The Plan 
denied your request. The Plan says that there is no documentation that the disease progressed on initial therapy. 
 
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 Keytruda. Our physician reviewer 
found that the enrollee has metastatic squamous cell cancer of the anus. He is on Carboplatin and Taxol, which 
noted a response. The requested use of Keytruda is supported by one of the major drug compendia for the 
enrollee's diagnosis as a second line treatment. It does not state there needs to be progression. The 
documentation does support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe 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 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 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of a Vertiflex Superion Indirect Decompression System (22869, 22870).You asked the Plan to pre-approvethe insertion of a Vertiflex Superion Indirect Decompression System. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental.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 insertion of a Vertiflex Superion Indirect Decompression System. Our reviewer says that the requested 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 the insertion of a Vertiflex Superion Indirect Decompression System have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of a Vertiflex Superion Indirect Decompression System (22869, 22870)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of a Watchman Left Atrial Appendage 
Occlusion Device on June 19, 2020. 
 
You asked the Plan to pay for the placement of a Watchman Left Atrial Appendage Occlusion Device. You say 
that the placement of Watchman Left Atrial Appendage Occlusion Device was medically necessary. The Plan 
denied your request. The Plan says the placement of Watchman Left Atrial Appendage Occlusion Device was 
not medically necessary. 
 
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 pay for the placement of a Watchman Left Atrial 
Appendage Occlusion Device. Our reviewer says that the placement of Watchman Left Atrial Appendage 
Occlusion Device was not medically necessary. Our physician reviewer found the enrollee is with a history of 
hypertension, hyperlipidemia, coronary artery disease, esophageal reflux, atrial fibrillation and obstructive 
sleep apnea. He was being prescribed Xarelto with no documented bleeding complications. He was admitted on 
6/18/2020 for elective placement of a Watchman device and discharged on 06/19/2020. There were no 
documented significant procedural complications. 
 
Based on the records the enrollee has atrial fibrillation and an elevated CHADS2 score but there is no 
documentation of either: 1. A formal shared decision making interaction with an independent non-
interventional physician using an evidence-based decision tool on oral anticoagulation or 2. Inability to take 
long-term oral anticoagulation.  Therefore the records do not support the medical necessity for a Watchman 
device. 
 
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 placement of a Watchman Left Atrial Appendage Occlusion Device have 
not been met. Therefore, we decided that the Plan does not have to pay for the placement of a Watchman Left 
Atrial Appendage Occlusion Device on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot, knee, hip, scanning fee, extra 
protective cover, and rotational units. 
 
You asked the Plan to pre-approve an advanced foot, knee, hip, scanning fee, extra protective cover, and 
rotational units. You say that the documentation provided supports the need for the requested items. The Plan 
denied your request. The Plan says the criteria for coverage have 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 an advanced foot, knee, hip, scanning 
fee, extra protective cover, and rotational units. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee had right AKA in 
December of 2019 due to aortic dissection complications, residual limb described as healthy. Co morbidities 
include COPD, Right Ear Nerve Disorder, HTN, GERD, right subclavian DVT, Aortic Aneurysm, Bacterial 
PNA. The enrollee has an active 4.4 cm aortic arch and descending thoracic aorta dilation. As per physical 
therapy notes from February 7, 2020, the enrollee is able to propel 150 feet with his wheelchair. The enrollee 
was approved for an above Knee and Hip Dysarthric prosthesis except for the advanced foot feature and an 
electronic knee under codes: L5961, L5828, L5845, L5848, L5856, L5981, and L5986. Medical progress notes 
from June 20, 2020, indicates the enrollee has phantom pain. A progress note from September 4, 2020, 
discusses the enrollee's phantom pain and says he is requesting a scooter for mobility. A document from 
December 23, 2020, notes the enrollee is wheelchair bound. The enrollee's right hip disarticulation healed, 
there are no focal neuro deficits, and there is no documentation of function in the note. The supporting treating 
medical practitioner progress notes do not indicate that the enrollee is a K3 ambulator. The requested items are 
not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of 
a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced foot, knee, hip, scanning fee, extra protective cover, and rotational 
units have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot, 
knee, hip, scanning fee, extra protective cover, and rotational units.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown provided on October 13, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown. You say that you live on social security, and thought some of this would be covered.The Plan denied your request. The Plan says these 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.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 pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for out of network physician services provided from April 9, 2020, to April 23, 2020.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care. Maximus overturned the Plans denial administratively because a 2020 Plan contract had not been submitted for review. The Plan requested a reopen and submitted the required contract information.

The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the services provided. Based on your contract with the Plan, we found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided from April 9, 2020, to April 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex spacer device.You asked the Plan to pre-approvethe device. The Plandenied your request. The Plan says this is not medically necessary.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this device is experimental. More research is needed to show safety and efficacy of the device. There is no documented spinal instability.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 havenot been met.Therefore, we decided that the Plan does not have to pre-approvethe Vertiflex spacer device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNovolog.You asked the Plan to pre-approvethe Novolog. You say that the enrollee is on multiple daily injections and is doing well with Novolog.The Plan denied your request. The Plan says the enrollee is a Medicare Advantage member with only Part B administered drug coverage through her contract. The Plan says that the drug is not administeredwith an insulin pump, the drug is coveredunder the pharmacy benefit.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-approveNovolog.Benefits for the Novologmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric hospital services.You asked the Plan to pre-approvethe inpatient psychiatric hospital services. You say that the records provided support the need for inpatient psychiatric care.The Plan denied your request. The Plan says the criteria for coverage of inpatient psychiatric care have not been met. The Plan says that long term custodial care is recommended.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not beenmet. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on December 8, 2020, with Bipolar Disorder Type I with Mood Congruent Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was found to be delusional but has been chronically nonfunctional. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. This enrollee did not appear to require inpatient mental health treatment beyond the date in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric hospital services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this procedure is helpful. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found bone marrow aspiration remains experimental for use in spinal surgery fusion procedures. More research 
is needed to show safety and efficacy. Iliac crest autogenous bone graft remains the gold standard. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for the enrollee.