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

 
We decided that the Plan does not have to pre-approve Repatha 140 mg/ml injection. 
 
You asked the Plan to pre-approve Repatha. You say that this service is medically necessary. The Plan denied 
your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical 
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-approve Repatha 140 mg/ml 
injection.  
 
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee's O2 saturation levels are not at 88% or below on room air. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success.  
 
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 services. Our physician 
reviewer found that the enrollee has a diagnoses of hypoxemia, shortness of breath, and contact with and 
(suspected) exposure to Covid-19. The documentation is insufficient to demonstrate that the enrollee's arterial 
PO 2 was at or below 55 mm Hg, or had an arterial oxygen saturation at or below 88 percent, taken at rest, 
breathing room air. There is no clinical evidence that supports supplemental oxygen is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home oxygen therapy.
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 an LTACH level of care is medically 
necessary for a continuation of care of complex respiratory and medical needs. The appellant says that the 
enrollee is stable for transfer. The Plan denied your request. The Plan says there are no required medical 
services in the LTACH that are not available in the approved hospital where the enrollee is.  
 
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 appears to be improving with treatment and only requires a short course 
of acute care services which can be safely completed in the current facility. 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 at this time. The enrollee's needs are 
not complex enough to warrant prolonged acute care services. Transfer to a lower level of care may be 
considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE). 
 
You asked the Plan to pre-approve a TTE. 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 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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is clinically stable with only mild valve irregularities on echocardiography about 
one year ago and no heart failure on physical exam. In this circumstance the records do not support the medical 
necessity for a repeat echocardiogram. Current guidelines also do not consider a repeat echocardiogram 
medically appropriate 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 a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE).
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 continued care at the requested facility is 
needed for wounds and further treatment. You say that the enrollee has not been doing well at the hospital and 
that survival is crucial. The Plan denied your request. The Plan says the records show the enrollee does not 
have an illness that is complex enough to require further hospital care. The Plan says that the records show the 
enrollee is recovering from an acute illness and will needed continued care. However, the Plan says that the 
enrollee can safely receive this care in another setting. 
 
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 appears to be improving with treatment and only requires a short course 
of acute care services which can be safely completed in the current facility. 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 at this time. The enrollee's needs are 
not complex enough to warrant prolonged acute care services. Transfer to a lower level of care may be 
considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the criteria for admission to the LTACH has not been met. Your 
medical needs are being met in the current acute setting. The LTACH would add no additional services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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. 
 
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. Specifically, the care you require is 
being met at the current acute inpatient level of care. There would be no additional services offered at the 
LTACH. This means the service is not reasonable or necessary.  Therefore, we decided that the Plan does not 
have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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. Medicare rules say that kyphoplasty is 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 lumbar magnetic resonance imaging 
(MRI) on January 7, 2021 showed no acute fracture of the L1 vertebra and mild retropulsion of the bone 
fragment arising from the superior endplate. Vertebroplasty is not indicated in chronic lumbar vertebral 
fractures or findings of vertebral retropulsion. Moreover, the request includes L2 kyphoplasty. There were no 
findings on the MRI that would indicate the need for kyphoplasty at this level. The enrollee did not meet all of 
the criteria for coverage and LCD L33473 for the kyphoplasty. Therefore, the request for L1 and L2 
kyphoplasty is not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has tried other drugs in the 
past, but they had to be discontinued due to side-effects. The Plan denied your request. The Plan says the denial 
of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does 
not administer the enrollee's Medicare Part D prescription drug benefits. 
 
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 Myrbetriq tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 30, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not request this service. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 30, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 30, 2020.
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 does not 
need an intensive multidisciplinary rehab program, or to be managed 3 times a week by a physical medicine 
doctor. 
 
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 presented to the acute hospital with right knee swelling, pain and discharge. He was treated 
with incision and drainage of the right knee, intravenous antibiotics and a wound vacuum device. He is non-
weight bearing with the right lower extremity. He is able to hop a few feet with minimum assistance and a 
rolling walker, is minimum assist for transfers, and minimum to moderate assist for activities of daily living.  
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. The enrollee does require physical and 
occupational therapy services, but does not require an intensive inpatient 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
Maximus upheld the Plans decision. Maximus then received additional information and decided to reopen the
case for a second review.
Our Medical Director reviewed the case file and the additional information. At issue is coverage for LTACH
services. Our Medical Director says that the enrollee is a 75-year-old man with a history of heart disease,
diabetes, Parkinson's disease, and hypertension, who was admitted to the acute care hospital on December 10,
2020 with acute respiratory failure due to infection with Covid-19. The enrollee required intubation. A
tracheostomy and PEG tube were placed on January 5, 2021. On January 14, 2021 the enrollee was undergoing
weaning with daily trach collar trials. He was tolerating tube feeds. It was noted that the enrollee was very
weak, and likely has a steroid myopathy and/or critical illness polyneuropathy. Aggressive physical therapy
will be needed. The enrollee is tolerating tube feeds. The enrollee is alert and oriented, and in no distress.
Determinations of medical necessity by Maximus Physician Reviewers are tailored to the individual patient and
their unique clinical scenario. In this case, a Maximus Physician Reviewer, with appropriate expertise and
qualifications, rendered an unbiased and well-considered opinion. The medical review was appropriate and
well-supported by documentation in the case file. 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. The documentation does not support that an additional 25 days of acute hospitalization are
reasonably expected for the enrollee in this case. 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a lower level of care will not be enough. 
You say that the enrollee needs to be seen by a rehab trained nurse and daily physicians to prevent emergency 
department visits. You say that the clinical information provided supports the need for an IRF level of care. 
The Plan denied your request. The Plan says the records show that the requirements for coverage of IRF care 
have not been met. The Plan says that the enrollee can receive the services needed in other settings. 
 
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 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. The enrollee 
was admitted for a stroke in August 2020. She has received care in a skilled nursing facility since her 
discharge. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH 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. 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 medically necessary. Our physician reviewer found the enrollee is 
currently undergoing treatment at an ACH (acute care hospital) for pneumonia with multiorgan dysfunction. 
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided on July 16, 2020. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the 
right to recover for services provided to eligible beneficiaries is not extinguished by plan requirements. The 
Plan denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth 
originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance 
services are combined and reported under revenue code 0510.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital services have not been met. Specifically, this claim has not been billed with the 
appropriate revenue code. Therefore, we decided that the Plan does not have to pay for the hospital services 
provided on July 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the implantation of a neurostimulator 
(63650) provided on September 1, 2020. 
 
You asked the Plan to waive the cost-sharing for the implantation of a neurostimulator. You say that you 
believe you were overcharged. The Plan denied your request. The Plan says this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $250 copayment after the $1000 deductible has been met 
for outpatient surgery services. 
 
You have been asked to pay $543 towards your deductible and a $250 copayment for the implantation of a 
neurostimulator , which is an outpatient surgery services. This cost sharing is a contractual obligation that had 
not been met at the time the implantation of a neurostimulator was received on September 1, 2020. Therefore, 
we decided that the Plan does not have to waive the cost-sharing for the implantation of a neurostimulator 
(63650) provided on September 1, 2020.