Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for a gadobutrol injection. We also decided that the Plan 
does not have to waive the cost share for an MRI.  
 
You asked the Plan to waive the cost share for an MRI. You say that if your doctor would have told you the 
cost of the services beforehand you would not have had the test done. You also say you cannot afford to pay for 
this service. The Plan says that you have been charged the correct cost sharing amount. 
 
 
 We decided that the Plan has to waive the cost share for a gadobutrol injection.  
 
The Plan says you must pay 20% coinsurance for a gadobutrol injection. According to Medicare a gadobutrol 
injection is considered a packaged code and is not separately payable. Therefore, we decided that the Plan has 
to waive the cost share for a gadobutrol injection.  
 
We also decided that the Plan does not have to waive the cost share for an MRI. 
 
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 $100 
copayment for an MRI.  
 
You have been asked to pay a $100 copayment for an MRI. An MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share 
for an MRI. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy tablet 50 mg. 
 
You asked the Plan to pre-approve Ubrelvy. You say that the requested drug is necessary. You also say that the 
enrollee is unable to take triptans due to palpitations. The Plan denied your request. The Plan says the requested 
drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part 
D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy tablet 50 mg.  
 Benefits for Ubrelvy may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 LTACH is medically necessary. The 
Plan denied your request. The Plan says authorization denied because the LTACH 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 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 record indicates that you require ongoing acute care services before transitioning 
to a lower level of care. The medical record does not indicate that you require services that you are not 
currently receiving but that would be available at the LTACH facility. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee is a patient who needs to 
receive dialysis treatment and also, given their bipolar condition, they do not have another transport or family 
members who can take them to the dialysis center. You also say that the patient's life runs the risk of not being 
able to continue with the treatment. The Plan denied your request. The Plan says the enrollee has exhausted the 
established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Eylea. 
 
You asked the Plan to pre-approve Eylea. 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 Eylea is not 
medically necessary. 
 
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 Eylea. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Eylea. Our physician reviewer found the 
requested use of Eylea is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This 
use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-
approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Eylea.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital 
on May 23, 2022 after a fall with a left hip fracture. You underwent surgery for the hip fracture the same day. 
You are now medically stable and do not require supervision by a physical medicine and rehabilitation physician three times per week for ongoing management of any active or acute worsening of your chronic 
medical conditions. You have no acute rehabilitation or nursing needs. While you may benefit from further 
therapy, you do not require the intensive therapy program 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (J1437). 
 
You asked the Plan to pre-approve Monoferric. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed (iron 
dextran) and Venofer (iron sucrose). 
 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 monoferric. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the enrollee has not tried and failed the 
preferred drugs, Infed and Venofer. The reviewer 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. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric (J1437).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 2 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee has 
suffered from this condition for 19 to 20 years and has failed 7 months of conservative approaches to treatment. 
You say that you recommend this minimally invasive procedure as a safer alternative when conservative 
treatment has failed. The Plan denied your request. The Plan says the requested procedure is considered 
experimental. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that Interspinous stabilization device remains 
experimental and more research is needed. 
 
  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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous rich plasma (PRP) for chronic 
wounds/ulcers (3C Patch) (G0460 x20). 
 
You asked the Plan to pre-approve autologous rich plasma (PRP) for chronic wounds/ulcers. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for services performed on or after April 
13, 2021, the Centers for Medicare & Medicaid Services (CMS) will cover autologous PRP for the treatment of 
chronic non-healing diabetic wounds under section 1862(a)(1)(A) of the Social Security Act (the Act) for a 
duration of 20 weeks, when prepared by devices whose Food and Drug Administration-cleared indications 
include the management of exuding cutaneous wounds, such as diabetic ulcers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of autologous rich plasma (PRP) for chronic wounds/ulcers have not been met. Therefore, we decided 
that the Plan does not have to pre-approve autologous rich plasma (PRP) for chronic wounds/ulcers (3C Patch) 
(G0460 x20).
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 that without intense rehabilitation and the physical 
therapist working with their family, the enrollee will not be able to return home, and this will reduce her quality 
of life. The Plan denied your request. The Plan says authorization denied because the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as 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 the enrollee's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/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: Favorable

 
We decided that the Plan has to approve additional inpatient hospital services. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
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 states that inpatient hospital services are not medically necessary; 
however, no medical records were received for review. MAXIMUS requested records from the Plan but the 
response did not contain valid records. Without medical records, a determination based on medical necessity 
cannot be supported. Therefore, we decided that the Plan has to approve additional inpatient hospital services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement. 
 
You asked the Plan to pre-approve the Vertiflex Superion device placement. You say that the enrollee has 
suffered from this condition for over 72 months and has failed over 72 months of conservative approaches 
treatment. You say that you recommend this minimally invasive procedure as a safer alternative when 
conservative treatment has failed. The Plan denied your request. The Plan says Medicare does not cover 
experimental and investigational services. 
 
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 Vertiflex Superion device 
placement. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Vertiflex device is experimental, and more 
research is needed. 
 
  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 Vertiflex Superion device placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion device placement.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  
 Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve Synthroid tablets. You say that she has tried the generic brand and is having 
side effects. You say that this is not as effective as the name brand and want to get her started as soon as 
possible. The Plan denied your request. The Plan says this medication falls under the pharmacy (drug) benefit. 
  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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Synthroid tablets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillofacial prosthetic procedure (21089). 
 
You asked the Plan to pre-approve a maxillofacial prosthetic procedure. You say that this service not truly 
dental, but medical. You also say that you had breast cancer and were placed on a drug called Aromasin which 
resulted in loss of bone in your mouth causing teeth to be lost. The Plan denied your request. The Plan says 
Medicare-covered dental services as covered services are limited to surgery of the jaw or related structures, 
setting of fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of 
neoplastic cancer disease, or services that would be covered when provided by a physician. The Plan also says 
that you do not currently have a fractured jaw nor are you preparing your jaw for radiation treatments. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillofacial prosthetic procedure (21089).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the service is necessary. The Plan denied 
your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.