Persius/hicric huggingface dataset:
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 needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing performed on January 5, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The requested specimen validity testing is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the specimen validity testing performed on 
January 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on August 
20, 2021, and November 14, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you were taken against your 
will and brought to the hospital. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay $250 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transport 
provided on August 20, 2021, and November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (Trilogy) (E0466). 
 
You asked the Plan to pre-approve a portable ventilator (Trilogy) (E0466). You say that the requested portable 
ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested portable ventilator (Trilogy) (E0466). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator (Trilogy) (E0466). 
Our reviewer says that the enrollee does not meet criteria for the requested portable ventilator (Trilogy) 
(E0466). Our physician reviewer found a home ventilator is not medically necessary. This enrollee has chronic 
obstructive pulmonary disease (COPD). There is no documentation of chronic CO2 retention on an ABG done 
while stable as an outpatient.  Medicare does not cover a home ventilator when used as BiPAP, which can provide the AVAPS mode of support. 
 
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 portable ventilator (Trilogy) (E0466) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a portable ventilator (Trilogy) (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for imaging provided on March 31, 2022. 
 
You asked the Plan to waive the copayment for imaging. You say that this was medically necessary since you 
are in so much pain. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $285 
copayment for each Medicare-covered diagnostic radiology service other than CT scan and performed by a 
provider other than your primary care physician.  
 
You have been asked to pay $285 copayment for imaging. Imaging falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for imaging provided on March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient mental health continued stay from August 
4, 2022, forward. 
 
You asked the Plan to pre-approve an inpatient mental health continued stay. You say that the enrollee is not 
ready to be discharged. You say that the enrollee's clinical status and deteriorated considerably over the past 
few weeks. You also say that the continued stay is medically necessary. The Plan denied your request. The Plan 
says the provided documentation does not support that the enrollee is having acute symptoms requiring 24-hour 
monitoring and support.  
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 an inpatient mental health continued 
stay. Our reviewer says that the requested inpatient mental health continued stay is not medically necessary 
beyond August 3, 2022. Our physician reviewer found that the enrollee did not appear to require inpatient 
mental health treatment beyond the date in question as she was not a danger to herself or others and does not 
have auditory or visual hallucinations. The documentation did not indicate that active treatment was taking 
place beyond the date in question. The documentation did not indicate that the services were reasonably 
expected to improve the enrollees condition or for the purpose of diagnosis beyond the date in question. 
Therefore, the reviewer found that the requested continued stay 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 an inpatient mental health continued stay have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an inpatient mental health continued stay from August 4, 
2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Padcev 20MG intravenous solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee is not using this drug for a medically accepted indication, and it is not 
covered under the enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the requested use of Padcev 20MG intravenous solution is not Food and Drug Administration (FDA)-
approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Padcev 20MG intravenous solution.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the knee (73719, 
73718, 73721, 73720, 73722, 73723). 
 
You asked the Plan to pre-approve an MRI of the knee. You say that a templating MRI is needed in order to 
build and correctly measure the knee for implantation. The Plan denied your request. The Plan says these 
services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the knee. Our reviewer says 
that an MRI of the knee is not medically reasonable and necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has osteoarthritis of the knee and may undergo partial knee 
arthroplasty. The medical record provided is insufficient to establish that the requested procedure is medically 
necessary to treat the enrollee's condition. The elements of the coverage criteria are not satisfied.   
 
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 MRI of the knee have not been met. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance imaging (MRI) of the knee (73719, 73718, 73721, 73720, 73722, 
73723).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest computed tomography (CT) scan for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no documentation of a change in the member's clinical 
state in comparison to when the CT of the chest was obtained on June 10, 2022. 
 
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 requested services are not considered medically reasonable and necessary in this case. The enrollee just had 
a CT scan on June 10, 2022. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a chest computed tomography (CT) scan for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the records show that in-network providers will provide the care 
you need. 
 
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 IRF care to be 
provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged endodontic therapy (root
canal) (D3310) and retreatment of previous root canal (D3346) provided on April 22, 2021.
You asked the Plan to waive or reduce this cost share. The Plan denied your request. The Plan says that the
schedule of benefits states that there is a $20 copayment for a root canal (D3310) and a $295 copayment for a
root canal retreatment (D3346). The Plan says this claim was processed correctly. Maximus overturned the
Plans denial for insufficient contract information to confirm this copayment. The Plan requested a reopen and
provided the required contract information.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plans dental contract states each of these services has a cost share. The Plan contract says that there is a
$20 copayment for code D3310 and a $295 copayment for code D3346. This cost share is your contractual
obligation. Therefore, we decided that the Plan does not have to waive or reduce the cost share for endodontic
therapy (root canal) (D3310) and retreatment of previous root canal (D3346) provided on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied 
your request. The Plan says rules for LTACH care have 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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a new lightweight wheelchair.
You asked the Plan to provide coverage for a new lightweight wheelchair. You say that a new wheelchair is
medically necessary. The Plan denied your request. The Plan says you were issued a new wheelchair in 2019.
Maximus overturned the Plans denial for lack of documentation to show you were provided with a wheelchair
in 2019. The Plan requested a reopen and submitted documentation to show you were given a wheelchair in
2019 and that you have confirmed you currently have that wheelchair and you have not returned it to the
supplier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only provides new equipment
every five years and if the equipment cannot be repaired. There is no documentation to show your current
equipment cannot be repaired and does not meet your ambulation needs in the home. Therefore, we decided
that the Plan does not have to provide coverage for a new lightweight wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the requested Udenyca is medically necessary. The 
Plan denied your request. The Plan says the requested Udenyca is not medically necessary. 
 
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 Udenyca. Our reviewer says that the 
requested Udenyca is not medically necessary. Our physician reviewer found the requested use for Udenyca is 
not FDA-approved for the enrollee's diagnosis. The risk of neutropenic fever is not greater than 20%. The use 
of Udenyca for the enrollee's diagnosis is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on January 5, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 
30-74 minutes of critical care services were provided on the date of service in question. 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 pay for the critical care services (99291) provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87640, 87653, 87798, 87641, 
87500, and 87801, billed for date of service November 8, 2021. 
 
You asked the Plan to pay for procedure code 87150, 87481, 87640, 87653, 87798, 87641. The Plan denied 
your request. The Plan says the billed codes are bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481, 87640, 87653, 87798, 87641 are column II codes to column I code 87150. We have also confirmed that 
code 87150 is a column II code to column I code 87500. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  
 
Medicare rules also say that the physician must clearly document, in the medical record, his or her intent that 
testing be performed. The records provided do not contain documentation of the ordering physicians intent 
that the services (87500, 87801) be performed. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87150, 87481, 87640, 87653, 87798, 87641, 87500, and 87801, billed for date of service 
November 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp for the enrollee. 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication the preferred drugs would likely be less effective, and/or cause 
adverse effects for the member. 
 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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary. The patient has not tried and failed Retacrit or Procrit. The 
documentation does not support that Retacrit or Procrit would likely be less effective, and/or would likely have 
adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not 
meet step therapy criteria for Aranesp.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.