Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF 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 you have stabilized medically. You do 
not have any complex wound care needs or nutrition given via a feeding tube. You are medically stable without 
any acute exacerbations of chronic medical problems. The documentation supports that your physical function 
is at or near baseline. The documentation does not support that you require 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, you do 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-approve admission to a skilled nursing facility (SNF).
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 needs to improve strength, endurance, 
activities of daily living, and mobility. The Plan denied your request. The Plan says the enrollee does not 
require intensive rehab, or to be directly under the care of physician supervision 
 
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 to the acute hospital for a thoracolumbar laminectomy. His medical problems are 
stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care.  The medical record supports a need for 
physical and occupational therapy, but 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.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, head or brain; without contrast material (CPT Code 70450). 
 
You asked the Plan to pre-approve the CT scan. You say that the imaging is necessary. The Plan denied your 
request. The Plan says that there is an approval code for the same study, or a similar study, that is on file in the 
member's records that has expired. The Plan states the clinical information provided for this review does not 
document results of the approved study(ies), or if the approval expired without being used. The Plan states 
guidelines do not support additional imaging without knowing the outcome of the prior approval and, therefore, 
the request is not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer 
found the fact that the prior study was not performed is not an excuse for not performing a study that is 
indicated. A head CT is central to the evaluation of the patient's neurologic symptoms. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT, head or brain; without contrast material (CPT Code 70450).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided at an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says there are in-network providers that can render the 
services. 
 
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 
physical therapy to be provided at an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive outpatient rehabilitation facility (CORF) 
services. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is at high risk for falls and can't 
complete most activities of daily living. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CORF services 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 enrollee was discharged from the 
hospital, with a new diagnosis of Parkinson's disease. She is medically stable and does not 
require intensive outpatient therapy services. Although further rehab services would be appropriate to improve 
function, as a practical matter, she does not require services from all three forms of therapy including Physical, 
Occupational and speech therapy. 
 
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 comprehensive outpatient rehabilitation facility (CORF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. 
The Superion spacer is considered experimental in nature, as more research is needed to show safety and 
efficacy. 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 Superion spacer.  
 
Local Coverage Determination (LCD) L34006 referenced by the Plan is not relevant to the services at issue and 
was not used in the MAXIMUS determination.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81201, 81162, 81242, 81298, 81317, 
81321, 81323, 81292, 81404, 81295) provided January 2, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you would like payment based on Medicare 
guidelines. The Plan denied your request. The Plan says an incorrect POS was used in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills, the place where the 
sample was taken is shown. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record shows that the specimen was taken 
in the office setting. This POS was not reported on the claim form. Therefore, we decided that the Plan does not 
have to pay for laboratory services (81201, 81162, 81242, 81298, 81317, 81321, 81323, 81292, 81404, 81295) 
provided January 2, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. 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. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is noted to have an elevated ferritin level, in the setting of a low iron level and 
normal iron saturation level. There is no evidence of hyperthyroidism, diabetes or leukemia. While the enrollee 
has a prior history of drinking, the enrollee reports infrequent drinking at present, has normal LFTs and 
negative hepatitis B studies. The enrollee reportedly has gout. It would appear that several causes of elevated 
ferritin have been excluded. While alcohol use and inflammation cannot be excluded as causes, neither can 
they be confirmed as causal by laboratory testing. Genetic testing could give a definitive diagnosis and would 
potentially affect treatment (transplant), testing (need for Bx) and the enrollee's family. As such, the requested 
genetic testing is currently shown to be medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve genetic testing.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need additional trips in order to get to 
dialysis appointments. The Plan denied your request. The Plan says you have used up the routine transportation 
benefit for the year. 
 
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 60 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 additional routine transportation trips.
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 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 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for shortly after discharge from hip surgery for avascular necrosis with shortness of breath and was 
treated for pneumonia and congestive heart failure.  Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this patient 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 acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete dentures (D5110). 
 
You asked the Plan to pre-approve the complete dentures. You say that you would like reconsideration because 
you accidentally threw away your dentures. The Plan denied your request. The Plan says this service exceeds 
the benefit allowance. 
 
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. Specifically, the record indicates that you received complete dentures 
on November 6, 2019. Your benefit allows for one complete denture every 60 months. Therefore, we decided 
that the Plan does not have to pre-approve complete dentures (D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nivolumab and ipilimumab. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic squamous 
cell lung cancer that has progressed after chemotherapy with Carboplatin/Abraxane/Keytruda and while on 
Keytruda. Her tumor has no actionable mutations and has PDL1 of one percent. The National Comprehensive 
Cancer Network (NCCN) compendium specifically states that the drug should be used as monotherapy only if 
there has not been progression on a PD-1/PDL1 inhibitor. The enrollee has progressed on Keytruda which is  
PD-1 inhibitor. Therefore the use, even as monotherapy does not meet the criteria for medically reasonable and 
necessary or safe and effective for the enrollee. Ipilimumab is not FDA indicated or compendium supported for 
use in this clinical setting. The use of Ipilimumab is not medically reasonable and necessary, nor is it safe and 
effective. The use of Nivolumab in combination with Ipilimumab is not FDA indicated or supported in any of 
the compendia. 
 
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 nivolumab and ipilimumab.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with COVID-19 pneumonia and acute respiratory failure. He is currently still requiring ventilation 
support, vasopressors, antibiotics, and diuresis. The enrollee does not require 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. 
 
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 Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the Plan 
requires a trial of drug Alendronate, Risedronate, or Ibandronate; and to try Zoledronic Acid (generic Reclast) 
before they will approve the requested drug. In this case, the member has not tried and failed the required drug, 
Zoledronic Acid. Our physician reviewer found there is no documentation provided indicating that the Plan?s 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest. 
 
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. Medicare rules say that CT scans 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have 
had extensive work-up for lung disease with prior chest x-rays. You have a cough and have been evaluated by 
an ear, nose, and throat (ENT) specialist. The prior chest x-ray is not suitable for a full diagnosis. There is 
adequate documentation that a CT scan of the chest is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the chest.  
 
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.