Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for inpatient hospital care provided from February 
17, 2022, to February 20, 2022. 
 
You asked the Plan to pay for physician's services for inpatient hospital care. You say that the physician's 
services for inpatient hospital care were medically necessary. The Plan denied your request. The Plan says that 
the medical records show that the member's condition meets the medical necessity criteria for an observation 
level of care. 
 
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 pay for physician's services for inpatient hospital 
care. Our reviewer says that the physician's services for inpatient hospital care are considered medically 
reasonable and necessary in this case. Our physician reviewer found that dialysis is a life sustaining therapy. 
This enrollee had missed one week of dialysis and had a blood urea nitrogen (BUN) of 125 mg/dl. The enrollee 
meets admission criteria with these alone. The admission was medically necessary and was at the level of 
standard of care that would be expected. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physician's services for inpatient hospital care have been met. Therefore, we 
decided that the Plan has to pay for physician's services for inpatient hospital care provided from  
February 17, 2022, to February 20, 2022. 
  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on May 19, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 for domiciliary or rest home visit provided on May 
19, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 2, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 for office visit provided on June 2, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that you more than qualify for this Medication, and 
would like the denial to be reconsidered. The Plan denied your request. The Plan says the use of this 
medication for shoulder arthritis is not an FDA indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Monovisc. Our reviewer says that 
Monovisc is not medically reasonable and necessary. Our physician reviewer found a Monovisc injection for 
shoulder osteoarthritis is not FDA-approved. The use of Monovisc for shoulder osteoarthritis 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. Our reviewer found that the use of Monovisc for shoulder 
osteoarthritis is not indicated, supported or recommended in any of the compendia. Our physician reviewer also 
found that the use of Monovisc for shoulder osteoarthritis does not meet Medicare criteria for safe and effective 
and otherwise 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three wheelchair with single power option and 
accessories. 
 
You asked the Plan to pre-approve a group three wheelchair with single power option and accessories. You say 
that you are unable to walk due to multiple medical conditions. The Plan denied your request. The Plan says the 
enrollee has a current power wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair received in 2019. Your current power wheelchair serves the 
same purpose as the requested group three wheelchair with single power option and accessories. Therefore, we 
decided that the Plan does not have to pre-approve a group three wheelchair with single power option and 
accessories.
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 disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy 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 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The provided records are 
insufficient to support that the enrollee has tried and failed an oral bisphonate drug and zoledronic acid. The 
record does not reliably indicate that the enrollee has a contraindication to or would have an adverse effect 
from an oral bisphonate drug and zoledronic acid. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee's recovery to regain maximum function. The Plan denied your request. The Plan says based on 
Medicare guidelines, the long-term acute care hospital services you are requesting do not meet the 
requirements for approval. 
 
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 has a medical history that includes heart disease, stroke, peripheral 
vascular disease, hypertension, diabetes, and chronic kidney disease. The enrollee was admitted to the acute 
care hospital on August 6, 2022, with a urinary tract infection, sepsis, and metabolic acidosis. The enrollee was 
treated with antibiotics and required dialysis. The hospital course was complicated by cardiac arrest on August 
7, 2022, requiring cardiopulmonary resuscitation (CPR) and intubation. The enrollee is now on room air and 
his mentation is back to his baseline.  Antibiotics have been stopped. Dialysis is no longer needed.  Skilled therapy is ongoing. 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. 
 
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 the LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a sleep study. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the provider is not a network provider, and the services were not urgent or 
emergent, nor were they approved in advance. 
 
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 for a sleep study provided on March 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99156 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 99156. You say that all charges were billed with different 
modifiers to avoid any bundling issues. You say that the charges should be processed and paid. The Plan 
denied your request. The Plan says there are no modifiers allowed with this code pair. 
  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 code 99156 
is a column II code to column I code 12013 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99156 billed for date of service March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefit. You say that you qualify for this benefit. The Plan 
denied your request. The Plan says the criteria to qualify you for this benefit has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefit have not been met. Specifically, the file does not support that you require 
intensive care management or are a high risk for hospitalization. Therefore, we decided that the Plan does not 
have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
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 you need inpatient rehabilitation services as soon as 
possible. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for IRF care. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
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: Surgery
Decision: Unfavorable

We decided the Plan does not have to provide coverage for Zio Patch cardiac event monitoring for the enrollee.
You asked the Plan to provide coverage for Zio Patch cardiac event monitoring. You say that Zio Patch cardiac
event monitoring is medically necessary for the enrollee. The Plan denied your request. The Plan says
Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Zio Patch cardiac
event monitoring. The Maximus Physician Reviewer determined that an ambulatory ECG monitor of 1 day to 2
weeks duration (but not a mobile cardiac outpatient telemetry monitor - MCOT), is reasonable to allow
assessment of rate control of the arrhythmia during day-to-day activities. The Plan has requested a re-opening,
stating that the Maximus reviewer's decision was in error in that it did not differentiate between the Zio AT
monitor and the Zio XT monitor. The Plan notes that Maximus was correct in asserting that mobile cardiac
outpatient telemetry (MCOT) monitor would not be appropriate which supports the denial. The Plan
notes that the enrollee had a history of atrial fibrillation. "Despite multiple requests for current medical records,
none were received. The most recent records provided were from 2019. There is no documentation of the
current need for home EKG services." The medical records show the enrollee was a then 89-year-old man with
a diagnosis of permanent atrial fibrillation, who presented on 12/20/21 for "AT ZIO monitor application." A
Holter monitor in September 2019 demonstrated that the enrollee was in atrial fibrillation 100% of the time,
with PVCs and runs of bradycardia. The case file does not contain clinical documentation stating the indication
for Zio Patch cardiac event monitoring. Zio AT is a real-time mobile cardiac telemetry monitor that is used for
higher-risk patients.
Our Medical Director has concluded that the Plan is correct in this case. The case file does not contain clinical
documentation of medical necessity for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zio Patch cardiac event monitoring have not been met. Therefore, we decided
that the Plan does not have to provide coverage for Zio Patch cardiac event monitoring for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D Histocytology rendered on November 16, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the records do not support a high 
likelihood of Barrett's esophagus in this enrollee. Therefore, regardless of the finding of short segment 
Barrett's, this does not meet the guidance relative to medically necessary use of the WATS-3D testing. The 
services were not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the WATS 3D Histocytology rendered on November 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the remaining 7 skilled nursing, 2 physical therapy (PT), 
and 2 occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the skilled nursing, PT, and OT visits. The Plan denied your request. The 
Plan says the enrollee does not currently meet the criteria for the requested number of skilled nursing visits for 
wound care because their wound is healed, and their caregiver is able to provide their skin care. The Plan also 
says that the enrollee does not meet the criteria for physical and occupational therapy visits because they have 
recently received these services and have not had a significant change in medical functional ability. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing, PT, and OT visits. 
Our reviewer says that the skilled nursing, PT, and OT visits are not medically reasonable and necessary. Our 
physician reviewer found the enrollee does not have a complex wound requiring skilled nursing services. The 
enrollee had completed PT without full recovery just a month prior, and had declined in function without 
change in health status. Our reviewer found that the enrollee can be retrained on a home exercise program, but 
does not require a continued PT or OT to regain function. Our physician reviewer also found that the enrollee 
can restore function with a home exercise 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 the skilled nursing, PT, and OT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the remaining 7 skilled nursing, 2 physical therapy (PT), and 2 
occupational therapy (OT) visits.