Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested 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 Injectafer. Our reviewer says that the 
enrollee does not meet the criteria for coverage for approval of Injectafer. Our physician reviewer found the 
enrollee has not tried and failed the required drugs, Infed and Venofer. Our reviewer also found that the 
documentation does not support that Infed and Venofer would likely be less effective, and/or would likely have 
adverse effects 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
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 clearly exceeds the 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving, but that would be available at the LTACH facility. Our reviewer found that the 
elements of the coverage rules are not satisfied. Our physician reviewer also found that the requested service 
cannot be recommended. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that your doctors want you to have more physical therapy 
because you cannot walk, bathe yourself, or perform any other functions. The Plan denied your request. The 
Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of care such as a 
skilled nursing facility (SNF). 
 
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 you were admitted for weakness and a urinary tract infection. The record shows your 
medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the patient's medical needs are being met at the current 
acute care setting and the LTACH would add no additional services. With additional time in the current setting, 
clinical stability care be ensured such that the appropriate lower level of care can be determined. 
 
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 patient is a 71-year-old male who was admitted to the acute care hospital with 
stroke with hemorrhagic conversion requiring hemicraniotomy, oxygen support complicated by pneumonia, 
acute kidney injury, C. Diff infection, encephalopathy, acute respiratory failure requiring intubation, trach 
placement, PEG placement, wound care, and antibiotics. Recent notes describe the patient as now tolerating 
trach collar, however, has most recent increased oxygen demand and imaging showing pneumonia requiring 
ongoing treatment. The patient appears to have been improving but recently unstable and should only require short-term additional acute care hospital services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The patient does not require services at the LTACH that are not 
already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended.  
 
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 custom-fit group 3 power wheelchair and accessories 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provided records do not show that a custom fit wheelchair is needed for care. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the enrollee 
lives in a skilled nursing facility, and a power wheelchair is primarily for use in the home. It is entirely unclear 
if the enrollee's caregivers are unable to manage a standard wheelchair. The enrollee is able to pressure fit 
based on activities of daily living function. The enrollee does not use a ventilator, and does not have myopathy, 
neurological impairment, or congenital soinal condition requiring a group 3 power wheelchair. 
 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve custom-fit group 3 power wheelchair and accessories for the enrollee.
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. The Plan denied your request. The Plan says that the 
coverage criteria 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 that the enrollee appears to be more stable and improving but requires additional 
acute care hospital services that can safely be provided at the current facility until more stable and appropriate 
for 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 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 prosthetic endoskeletal system, below knee,
align-able system represented by code L5910.
You asked the Plan to provide coverage for this request. You say that at the time of the appeal, these prosthetic
components were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not follow the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an addition,
endoskeletal system, below knee, align-able system represented by code L5910.
The Maximus Physician Reviewer determined that the criteria for coverage were met. The Plan requested a
reopen and stated that "Per Medicare guidelines, "Records from suppliers or healthcare professionals with a
financial interest in the claim outcome are not considered sufficient by themselves for determining that an item
is reasonable and necessary." The prosthetist is the vendor and therefore has financial interest in the outcome of
the claim. While the signed physician order includes L5910, per Medicare rules, "A prescription is not
considered to be part of the medical record. Medical information intended to demonstrate compliance with
coverage criteria may be included on the prescription but must be corroborated by information contained in the
medical record." The notes do not show why member's current L5910 Align-able System cannot be used." The
plan notes that the align-able system does not have any effect on socket fit, and notes that the current align-able
system is less than one year old.
The plan is correct in this case. There is insufficient clinical documentation supporting that an addition,
endoskeletal system, below knee, align-able system was medically reasonable and necessary 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 this request have not been met. Therefore, we decided that the Plan
does not have to provide coverage for a prosthetic endoskeletal system, below knee, align-able system
represented by code L5910.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure. 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that Medicare has approved the use of 
Vertiflex. You say that spinal surgery would be more invasive and dangerous than the Vertiflex procedure, 
which would be more cautious and less expensive. The Plan denied your request. The Plan says the requested 
procedure is unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer 
says that a Vertiflex procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental. More research is needed to show safety and efficacy. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lntracept Procedure (interosseous radiofrequency 
ablation 64628, 64629). 
 
You asked the Plan to pre-approve a lntracept Procedure. You say that it is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lntracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. It is unproven and 
not medically necessary due to insufficient evidence of efficacy. 
 
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 lntracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lntracept Procedure (interosseous radiofrequency ablation 64628, 64629).
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria 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 that the medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be recommended. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request does not meet the plan's step therapy criteria for this 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of Infed and Venofer before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monoferric for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder arthroscopy procedure (29823, 29826, 2987) 
to be performed in an outpatient hospital setting. 
 
You asked the Plan to pre-approve a shoulder arthroscopy in an outpatient hospital. You say that the requested 
setting is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested setting 
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 a shoulder arthroscopy in an outpatient 
hospital. Our reviewer says that the provision of the requested services in an outpatient hospital setting is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that detailed 
documentation is not evident regarding significant co-morbidities that would preclude the enrollee from having 
the approved arthroscopic surgery in an ambulatory surgery center. The enrollee has a past medical history of 
hypertension that is noted to be well-controlled and is currently taking medications for this condition. Without 
any other significant co-morbidities, there are no significant increased risk factors to prevent this enrollee from 
undergoing surgery in the ambulatory surgery center. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 shoulder arthroscopy in an outpatient hospital have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a shoulder arthroscopy procedure (29823, 29826, 2987) 
to be performed in an outpatient hospital setting.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol. 
 
You asked the Plan to pre-approve Ferumoxytol. You say that you are not able to care for yourself without the 
infusions. The Plan denied your request. The Plan says you have not tried and failed the preferred step therapy 
drugs. 
 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 Ferumoxytol. Our physician reviewer 
found that you have iron deficiency anemia. The requested medication is a new start. The Plan requires a trial 
of Infed and Venofer before they will approve the requested drug. The provided records do not indicate that 
you have tried and failed the Plan's preferred step one alternative. The record does not indicate that you have a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative.  The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the CT scan provided in an outpatient
hospital on November 2, 2021.
You asked the Plan to reduce the copayment for the CT scan. You say that you paid $125 for a CT scan and
now you have received a bill for an additional $150. The Plan denied your request. The Plan says this cost
sharing was charged correctly.
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 $275
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You
initially paid $125 for the CT scan You have been asked to pay an additional $150 for a total $275 copayment
for the CT scan. The CT scan was provided in an outpatient hospital setting and not in a physician's office or a
free-standing facility. This item/service falls within the Medicare-covered surgery or other services provided to
you at an outpatient hospital 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 reduce the copayment for the CT scan provided in an outpatient hospital
on November 2, 2021.