Persius/hicric huggingface dataset:
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 the enrollee is stable and suitable for 
transfer to LTACH. The Plan denied your request. The Plan says based on Medicare guidelines the LTACH 
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 with a past medical history of recent lumbar spine surgery for 
degenerative disc disease, hypertension, hyperlipidemia, depression and schizophrenia who presented to the 
acute hospital on August 9, 2022 with a lumbar wound dehiscence with infection. The enrollee was treated in 
the hospital with intravenous antibiotics and a wound vacuum device and the condition stabilized. The enrollee 
was reported to be medically stable on August 25, 2022 and discharged to home with home health services with 
intravenous Ancef via a peripherally inserted central catheter line and wound vacuum therapy for the back 
wound and otherwise the enrollee was on outpatient medications.  The enrollee is weak and deconditioned and is working with home health services. The enrollee is dependent 
for mobility and is maximum assist for transfers and activities of daily living. The enrollee has discharged from 
the short term acute care hospital to home and the records do not document the need for further hospital level 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you have back pain, broke your arm, and 
have carpal tunnel. The Plan denied your request. The Plan says the requested provider is not a covered 
provider type and is not under the supervision of one. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are only covered when provided 
by a physician, PA, or NP/CNS, or under the direct supervision of one of these covered providers. The Plan 
contract says that acupuncture must be provided in network. The requested provider is not in network and is not 
a qualified provider under Medicare guidelines. Therefore, we decided that the Plan does not have to pre-
approve out of network acupuncture services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
tried and failed the preferred drug. 
 
 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 Evenity. Our physician reviewer found 
that the record indicates that the enrollee has age related osteoporosis without osteoporotic fracture. The 
requested medication is a new start. The Plan requires a trial of Forteo before they will approve the requested 
drug. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the Plan's preferred step one alternative. Therefore, 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac rhythm monitor. 
 
You asked the Plan to pre-approve cardiac rhythm monitor. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this is 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 cardiac rhythm monitor. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient clinical evidence to support the appropriateness and necessity of 
replacing the enrollee's old implantable loop recorder with a new one. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac rhythm monitor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac rhythm monitor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued SNF admission. 
 
You asked the Plan to pre-approve the continued SNF admission. You say that you are requesting 
reconsideration stating you wish the denied SNF admission to be approved. The Plan denied your request. The 
Plan says based on Medicare guidelines and the SNF services requested do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF admission. Our 
reviewer says that as of August 18, 2022 the enrollee was walking 10 feet with a platform walker with 
maximum assistance and was maximum assist for transfers and most activities of daily living. The enrollee 
otherwise was reported to be medically stable for discharge on outpatient medications. Our physician reviewer 
found the enrollee is an 81 year old with a past medical history of a stroke with aphasia and dysphagia, 
diabetes, hypertension hyperlipidemia and a pacemaker who presented to the acute hospital on July 25, 2022 
with a fall. The enrollee was evaluated and treated in the hospital and stabilized and was transferred to a skilled 
nursing facility for skilled nursing and therapy services on August 6, 2022. The enrollee is weak and 
deconditioned and is working with physical and occupational therapy. The enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. Our reviewer also found that the enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF admission. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued SNF admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 71046. 
 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 71045 
is a column II code to column I code 71046. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan 
requires a trial of Ferrlecit, Infed, or Venofer. 
 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 Feraheme. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Feraheme. Our physician reviewer 
found there is no indication that the enrollee has tried and failed the Plan's preferred drugs of Ferrlecit, Infed, or 
Venofer. The record does not show that these drugs would likely be less effective and/or have adverse effects 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided from February 25, 
2022, to February 27, 2022. 
 
You asked the Plan to pay for critical care services. You say that this was billed correctly. The Plan denied 
your request. The Plan says the records do not document the time spent on these services. 
 
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 time spent on critical 
care services is not documented in the submitted records. Based on this information, we decided that Medicare 
rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have 
to pay for critical care services (99291) provided from February 25, 2022, to February 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency-department services from 
March 30, 2022, to April 1, 2022 or to pay for self-administered drugs provided on March 30, 2022, to April 1, 
2022. 
 
You asked the Plan to waive the copayment for emergency-department services. You say that the services at 
issue were a medical necessity for you. The Plan denied your request. The Plan says the correct copayment for 
the emergency-department services at issue was applied. Rules for payment for self-administered drugs have 
not been met. 
 
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 a $90 
copayment for emergency services.  
 
You have been asked to pay a $90 copayment for emergency-department services. Emergency-department 
services fall within the Emergency Care 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. 
 
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 at issue here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to waive the copayment for emergency-
department services from March 30, 2022, to April 1, 2022 or to pay for self-administered drugs provided on 
March 30, 2022, to April 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. The enrollee is not shown to have an acute decline 
in function. Daily skilled services are not shown to be required to establish a maintenance program or to 
prevent deterioration of the enrollees condition.  The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve the IRF admission. You say that you require this care because you are 
unable to care for yourself, and less intensive therapy has not helped you to regain strength. The Plan denied 
your request. The Plan says that medical records were requested but were not submitted. Without records, the 
medical necessity of the IRF care cannot be determined. Per the Parts C & D Enrollee Grievances, 
Organization/Coverage Determinations, and Appeals Guidance, Section 10.6, when additional information 
requested is not received, a determination must be made with the documentation at hand. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted medical records to Maximus, meaning that an 
independent review of the denial cannot be performed. The providers at issue are in-network with the Plan, and 
records from network providers are considered within the Plan's control. Maximus may elect to request missing 
information and extend the appeal time frame if doing so is in the best interest of the enrollee. We do not find 
that extending the time frame to obtain these records is in the enrollee's best interest as it unduly delays 
potentially medically necessary care. As such, we find that the Plan has not substantiated the denial in this case. 
Therefore, we decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).  
 
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: 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 admission is medically necessary. The Plan 
denied your request. The Plan says the admission is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 the provided documentation does not indicate that the enrollee requires the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. Therefore, the reviewer found that the requested IRF 
admission 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 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on January 20, 
2022. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for psychotherapy 
services have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on 
January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of permanent cardiac contractility modulation 
(CCM) system. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that while clinical studies led to FDA approval in 2019, CCM remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. At the current time, the CCM system is not considered to be medically 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of permanent cardiac contractility modulation (CCM) system.