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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the documentation does not support that the requested drug meets 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain related to osteoarthritis, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not support 
that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or likely 
have adverse effects for the enrollee. 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
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 enrollee needs more care than can be 
provided at a skilled nursing facility. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested LTACH services 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where care is currently being provided. All medically necessary care is being provided in 
the current acute care setting. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in targeted tidal volume, volume-
assured pressure support (TTV-VAPS) mode with Auto-EPAP (AE) that could be delivered by bilateral 
positive airway pressure (BiPAP) is not covered. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have a 
diagnosis of chronic obstructive pulmonary disease (COPD), but there are no pulmonary function tests to 
assess severity. You were recently hospitalized with acute respiratory failure, due to a presumed COPD exacerbation, but also from acute pulmonary edema and alcohol intoxication. The arterial blood gas (ABG) on 
admission is consistent with acute ventilator failure, and the PaCO2 normalized on BiPAP by the next day. 
Thus it appears the patient does not have chronic CO2 retention.  Even if the patient did have chronic CO2 
retention, Medicare does not cover a home ventilator when used as BiPAP, and the AVAPS mode of support 
can be provided via BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is currently having issues with balance, 
strength and has weakness in his knees. The Plan denied your request. The Plan says IRF care is not medically 
necessary and the enrollee's needs can be met at a lower level of care such as in a skilled nursing facility or in a 
long-term care setting. 
 
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 while the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services that an IRF would provide. Our 
physician reviewer found that there is no complex nursing or rehabilitation needs. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide an exception to the 50-mile limit for routine transportation.
You asked the Plan to provide an exception to the 50-mile limit for routine transportation. You say that this exception is necessary to allow you to see a provider. The Plan denied your request. The Plan says exceptions are not allowed to supplemental transportation benefits. Maximus overturned the Plans decision because the case file lacked a Plan contract. The Plan requested a reopen and provided a copy of the required contract.
The Plan is correct in this case. Medicare does not cover routine transportation. The Plan covers routine transportation with a limit of 50 miles one way. You are requesting a destination 76 miles away from your home. Neither the Plan nor Medicare makes exceptions for supplemental benefits. Therefore, we decided that the Plan does not have to provide an exception to the 50-mile limit for routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the 
sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and 
interpretation, and pulmonary artery angiography, when performed (33289) and an implantable wireless 
pulmonary artery pressure sensor with delivery catheter (C2624). 
 
You asked the Plan to pre-approve outpatient procedure. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the clinical information received for appeal did not 
establish medical necessity for the requested service. 
 
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 outpatient procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart 
catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary 
artery angiography, when performed (33289) and an implantable wireless pulmonary artery pressure sensor 
with delivery catheter (C2624).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided on February 14, 
2022. 
 
You asked the Plan to pay for the ER services as billed. You say that the Plan is required to make payment for 
these COVID-related services. The Plan denied your request. The Plan says this outpatient hospital claim was 
billed with an invalid code, 93000. This code causes the claim to be returned to provider. A corrected claim 
must be submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that I/OCE edits are used to prevent improper 
payments under the OPPS.   
We looked at the file and Medicare rules. This claim was billed with code 93000. This code has a status 
indicator of M in the OPPS. This invoked edit 72, which correctly returned the claim to provider. The provider 
must fix the billing issues and submit a corrected claim. Based on this information, we decided that Medicare 
rules for coverage of the ER services as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency room (ER) services provided on February 14, 2022.
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where care is currently being provided. All medically necessary care is being provided in 
the current acute care setting. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for outpatient imaging and contrast material provided on October 9, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by the provider and the Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct contract language or Medicare billing guidelines. The Plan demonstrated that the billing guidelines used by Maximus do not apply. The Plan demonstrated that the Medicare guidelines show chemical supplies provided by facilities while treatment can be charged separately and can also incur a cost share. The Plan demonstrated that according to the Fee Schedule for code A9584, the Medicare allowed amount for this contrast is $2,813.52. Twenty percent coinsurance for this contrast material would be $562.70.
The Plan is correct in this case. 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 20% coinsurance for outpatient diagnostic supplies. 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 or reduce the cost share charged for outpatient imaging and contrast material provided on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient mental health facility admission provided 
by a participating provider. 
 
You asked the Plan to pre-approve an inpatient mental health facility admission. You say that an admission is 
medical necessity for the enrollee since they are still suicidal. The Plan denied your request. The Plan says the 
enrollee is feeling better, and this admission is not medically necessary. 
 
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 facility 
admission. Our reviewer says that the medical criteria for an inpatient mental health admission has not been 
met. Our physician reviewer found it did not appear that active treatment was taking place beyond the date in 
question. It did not appear that the services for the dates in question were reasonably expected or medically 
necessary to improve the enrollee's condition or for the purpose of diagnosis. 
 
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 facility admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an inpatient mental health facility admission provided by a 
participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of soft tissue localization device (10035) provided on May 13, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the plan. The Plan denied your request. The Plan says these services were covered in a previous claim. Maximus overturned the Plans denial for lack of documentation to show these services were previously paid. The Plan requested a reopen and provided additional information. The Plan states they were told to pay code 10035 because they did not submit a claim showing code 19083 was billed on the same date in which code 10035 would have been included. In the reopen the Plan provided documentation to show the provider billed two separate claims for this dated of service. Code 19083 was billed on a different claim in error and cannot be paid as billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary, the appropriate modifiers. In this case, code 10035 was billed separately without the required modifier. Therefore, we decided that the Plan does not have to pay for the placement of soft tissue localization device (10035) provided on May 13, 2020.
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 this admission is medically necessary. 
The Plan denied your request. The Plan says medical criteria for an LTACH admission has 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 all medically necessary care is being provided in the current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a nebulizer (E0570) purchased on August 23, 2021.
You asked the Plan to pay for this equipment. You say that you do not understand why the Plan pays for the medication but not the nebulizer. The Plan denied your request. The Plan says this type of nebulizer is a capped rental item and cannot be purchased outright to be covered by the Plan. Maximus overturned the Plans denial for insufficient explanation on their denial. The Plan requested a reopen and provided documentation to show that based on the Durable Medical Equipment Prosthetics, Orthotics, and Supplies April 2021 Fee Schedule, code E0570 is a capped rental item. Purchase is not allowed until 15 months of payments are satisfied.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get prior authorization. Medicare does not allow the direct purchase of capped rental items. You purchased this equipment out of network and without prior authorization. You did not follow your contract rules when you purchased this equipment. Had the provider requested prior authorization, they would have been informed of your contract agreement regarding capped rental items. Therefore, we decided that the Plan does not have to pay for a nebulizer (E0570) purchased out of network on August 23, 2021.
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 records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. Although records document you are very limited 
functionally, provided records do not document a significant decline in your functional status compared to your 
recent baseline to necessitate daily inpatient skilled therapy services. You do not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the long-term 
care facility on a part time basis are not appropriate 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 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: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for shoulder arthroscopy (29822) provided on May 26, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus administratively overturned the Plans denial as no medical records were included in the case file for review. The Plan requested a reopen and submitted the medical records sent with the claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. Based on the medical records provided, there is insufficient information in the record to determine if the Medicare rules for coverage of shoulder arthroscopy were met. Therefore, we decided that the Plan does not have to pay for shoulder arthroscopy (29822) provided on May 26, 2021.