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

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy with rotator cuff repair 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 there are more conservative treatments available that have not been done yet. 
 
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 in this case, the enrollee complained of shoulder pain resulting in a request for left shoulder arthroscopy 
with debridement, subacromial decompression with partial acromioplasty with or without coracoacromial 
release and arthroscopic rotator cuff repair. The request was denied due to a lack of diagnostic imaging 
demonstrating any internal derangement. There was no advanced diagnostic testing performed. The reason no 
MRI was performed is because the enrollee has a brain stimulator. There were no other diagnostic tests 
performed that documented any internal derangement that would necessitate the requested surgical procedure.  
In addition, there is a lack of recent detailed/comprehensive physical exam findings provided evidencing a 
strong clinical indication for surgical intervention as proposed. Therefore, the requested left shoulder 
arthroscopy with debridement, subacromial decompression with partial acromioplasty with or without 
coracoacromial release, and arthroscopic rotator cuff repair 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve shoulder arthroscopy with rotator cuff repair for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 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 Humira.  
 
Benefits for Humira 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: 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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the records show that the enrollee is medically stable and does not 
need to be seen by a doctor every day. 
 
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's ongoing care needs include oxygen supplementation with weaning, 
intravenous steroids, surveillance laboratory studies, and therapy services. The documentation does not support 
that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. There are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy. 
 
You asked the Plan to pre-approve Yervoy. You say that the enrollee needs systemic therapy again for 
recurrent disease. The Plan denied your request. The Plan says the enrollee does not have a medically-accepted 
indication. 
 
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 Yervoy. Our physician reviewer found 
that the enrollee has peritoneal mesothelioma. The requested use of Yervoy is not FDA-approved for the 
enrollee's condition. The use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. The documentation does not 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 Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional chiropractic visits. 
 
You asked the Plan to pre-approve the 8 additional chiropractic visits. You say that it is imperative to the 
enrollee's health that he continue treatment. You say that the enrollee has noticed a regression in health and a 
return of symptoms since being denied additional treatment. The Plan denied your request. The Plan says the 
requested chiropractic therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 8 additional chiropractic visits Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found there are no 
submitted imaging studies to reveal evidence of a subluxation. The submitted documentation, including a daily 
visit note, dated January 2, 2021, reveals the following findings: myospasm of the lumbar spine, tenderness to 
palpation and edema of the lumbar spine, myospasm and tenderness to palpation of the cervical area, restricted 
cervical and lumbar ranges of motion (no arcs of motion are given), misalignment of the neck, upper mid back, 
low back, sacrum and sacroiliac joints, pain/tenderness of moderate intensity and tissue tone changes 
(hypertonic) of the paralumbar, bilateral quadratus lumborum and right psoas {muscles} of moderate intensity. 
These findings do not reveal evidence of subluxation per Medicare guidelines. Thus, chiropractic treatment is 
neither supported nor allowed per Medicare guidelines. 
 
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 8 additional chiropractic visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional chiropractic visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that the enrollee has severe COPD. The Plan denied 
your request. The Plan says this drug is not covered for the enrollee's condition by Medicare 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.  
 
Benefits for Prednisone 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: 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 enrollee is extremely weak and having 
trouble with activities of daily living. You say that the enrollee does not have any assistance at home and is 
uncomfortable leaving the hospital in fear of falling. You say that the enrollee is not at her baseline of strength 
due to CoViD. The Plan denied your request. The Plan says the criteria for coverage of SNF care have not been 
met. 
 
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 enrollee has stabilized medically 
and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled 
therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level 
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is 
medically stable without any acute exacerbations of chronic medical problems. Her physical function is near 
her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehab services is not medically necessary. She does not require any skilled nursing 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is not a candidate for platinum based 
therapy, given his age and comorbidities. The Plan denied your request. The Plan says guidelines do not 
support use of single-agent Keytruda as first line therapy for the enrollee's condition. 
 
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 a diagnosis of metastatic squamous cell esophageal cancer. The requested use of 
Keytruda 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. There is no compendia 
basis or literature support for first line Keytruda in metastatic esophagus cancer. The documentation does not 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is able to participate in therapy and 
requires close medical oversight. The Plan denied your request. The Plan says the enrollee does not require an 
intensive multi-disciplinary therapy program to reach his goals. 
 
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 was admitted to the hospital and underwent triple coronary artery bypass 
on January 19, 2021. The patient required minimum assistance for bed mobility. The patient requires moderate 
assistance for transfers. He requires min/mod assist with upper body dressing and moderate assist with lower 
body dressing. The patient can ambulate thirty feet with a rolling walker plus minimum assistance. 
 
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not 
require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in 
multiple therapies, the patients functional level does not require this on an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fosaprepitant injections (J1453). 
 
You asked the Plan to pre-approve Fosaprepitant. You say that Fosaprepritant is medically necessary. The Plan 
denied your request. The Plan says Fosaprepritant is not medically necessary until a chemotherapy regime has 
been started. 
 
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 Fosaprepitant. Our reviewer says that 
this drug is not medically necessary at this time. Our physician reviewer found the enrollee has not had PD-L1 
testing or ALK/EGFR testing. Results of these tests could alter her treatment regimen and need for 
Fosaprepritant. Until these tests are performed and a treatment regimen has been determined the service is 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 Fosaprepitant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fosaprepitant injections (J1453).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric diagnostic evaluation provided on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foran OON psychiatric diagnostic evaluation. You say that the hospital staff should have obtained authorization.The Plan denied your request. The Plan says authorization was required and 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 psychiatric diagnostic evaluation provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric services.You asked the Plan to pre-approvethe inpatient psychiatric services. You say that inpatient mental health services are medically necessary until the enrollee is stabilized.The Plan denied your request. The Plan says the information provided does not meet the guidelines for acute inpatient psychiatric treatment.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 services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on December 3, 2020, with Schizoaffective Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. 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 he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations.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 inpatient psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network mental health services. 
 
You asked the Plan to pre-approve out of network mental health services. You say that you prefer to see the 
requested provider. The Plan denied your request. The Plan says the requested provider is not 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 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 out of 
network mental health services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for Vitamin B12 testing (82607) provided to the enrollee on December 3, 2019.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this test was previously provided in March 2019 and is only covered once per year. Therefore, the testing in December 2019 exceeded the Medicare benefit. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information regarding this claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare does not cover multiple vitamin deficiency assays as they are considered screenings. 

In this case, the Plan has provided documentation that the enrollee has this lab service in March of 2019. Therefore, the service provided in December 2019 exceeds frequency limits and would be considered a screening. The records also do not show the enrollee had prior authorization for this service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin B12 testing (82607) provided to the enrollee on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to the furniture part of your lift chair.

You asked the Planto pre-approve the requested repairs. You say that when you sit, the chair goes down to the floor.The Plan denied your request. The Plan says Medicare does not pay for furniture, or repairs to furniture.

The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. 

We looked at the file and Medicare rules.Although a seat lift chair may be appropriate, Medicare does not cover this item. Services related to non-covered services, such as repairs, are non-covered.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvere pairs to the furniture part of your lift chair.