Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 more home skilled nursing services (G0299 x2). 
 
You asked the Plan to pre-approve additional skilled nursing services. You say that you would like to appeal 
these services. The Plan denied your request. The Plan says the records do not support the need for a skilled 
nurse to make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional skilled nursing services. Our 
reviewer says that additional skilled nursing services are not reasonable and necessary. Our physician reviewer 
found you are receiving repetitive observation and teaching for relatively stable chronic conditions you manage 
with knowledge of your medications and diet. The wound does not require skilled nursing services. Our 
reviewer also found that the record does not support continued services, as your condition is stable with low 
risk for exacerbation and your chronic stasis ulcer is quite stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 more home skilled nursing services (G0299 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty not in conjunction with extractions 
(D7320) provided by a participating provider. 
 
You asked the Plan to pre-approve an alveoloplasty not in conjunction with extractions. You say that these 
services are medically necessary for you. The Plan denied your request. The Plan says the requested dental 
service is not a covered benefit. 
 
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 an 
alveoloplasty not in conjunction with extractions (D7320) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has no significant acute illness which has compromised his function and does not have complex or intensive rehabilitation needs. Our physician reviewer also found that he does not 
require frequent physiatry oversight as his rehabilitation needs are routine following a period of decline in the 
setting of chronic loss. Our physician reviewer also found no autonomic instability and no new neurological 
deficits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIP interspinous fixation system. 
 
You asked the Plan to pre-approve Aurora Spine ZIP. You say that the enrollee needs this procedure to get pain 
relief and quality of life. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the clinical value and effectiveness of Aurora Spine ZIP has not been demonstrated. 
 
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 Aurora Spine ZIP. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence-based medical guidelines do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There were no imaging studies 
provided for review. There is no compelling rationale or extenuating circumstance 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 Aurora Spine ZIP have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Aurora Spine ZIP interspinous fixation system.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency stretcher transportation services provided to
the enrollee on January 20, 2022.
You asked the Plan to pay for non-emergency stretcher transportation services provided to the enrollee. You
stated that the Plans approved provider cancelled two days prior to a scheduled appointment for which the
enrollee needed this transportation. You stated you had no choice but to find a provider right away that could
accommodate a stretcher for transport. The Plan denied your request. The Plan stated that this type of
transportation provider is not covered by Medicare. Maximus upheld the Plans denial based on the Medicare
rules. You requested a reopen and provided additional information for review that you believe was not
available to us at the time of our first review.
Based on review of the case file and the additional information submitted with your reopen request, we find the
Plans denial and our original decision were correct in this case. The Plan must follow Medicare rules. The rules
say that Medicare does not pay for transport services other than those provided by an ambulance. The records
provided in both your appeal and the reopen request show this transportation was arranged with an out of
network provider and payment was made with a credit card for $350. The providers website indicates that
while they are equipped to provide non-emergency stretcher transportation, they are not considered either
commercially or by Medicare to be an ambulance company. The enrollee also did not have prior authorization
from the Plan for this transport.
The services you have asked the Plan to pay for are not a type of transport covered by Medicare. The provider's
vehicles are not ambulances. The provider is not in network. The enrollee did not have prior authorization.
Therefore, we decided that the Plan does not have to pay for non-emergency stretcher transportation
services provided to the enrollee on January 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone sodium phosphate injection. 
 
You asked the Plan to pre-approve Dexamethasone sodium phosphate injection. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Dexamethasone sodium phosphate 
injection. Our reviewer says that the documentation does not support that the requested drug is medically 
reasonable or necessary. Our physician reviewer found you have back pain. The record indicates this code was 
submitted in error. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. 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 Dexamethasone sodium phosphate injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Dexamethasone sodium phosphate injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued 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 further daily skilled services are required. Although records document the enrollee is very limited functionally, provided records do not document a significant improvement in the enrollee's functional status despite daily inpatient skilled speech, physical and occupational therapy services to necessitate further daily inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services in a 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement procedures performed on 
September 16, 2021, to October 7, 2021. 
 
You asked the Plan to waive the copayment for debridement procedures performed on September 16, 2021, to 
October 7, 2021. You say that you were not aware of your copayment. The Plan denied your request. The Plan 
says you must pay a $150 copayment per visit to an outpatient hospital facility. 
 
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 $150 
per visit copayment to an outpatient hospital facility. There were three visits, resulting in a total copayment 
amount of $450. 
 
You have been asked to pay a $150 per visit copayment for debridement procedures performed on September 16, 2021, to October 7, 2021. Debridement procedures fall within the Outpatient Surgery, Including Services 
Provided At Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for debridement procedures performed on September 16, 2021, to 
October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and drugs or 
medicaments dispensed in the office for home use (D9630). 
 
You asked the Plan to pre-approve the bone replacement graft and drugs or medicaments. You say that you feel 
the bone graft is very important to stop the drifting of the teeth since the first tooth next to the extraction 
supports a 5-tooth bridge and the area behind it will have no support at all without the bone graft. The Plan 
denied your request. The Plan says these services are not covered expenses under your dental plan. 
 
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 
bone replacement graft (D4263) and drugs or medicaments dispensed in the office for home use (D9630).
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 the enrollee is stable for transport and 
exceeds the Medicare guidelines for LTACH services. The Plan denied your request. The Plan says the records 
do not show that the physicians expect the enrollee will benefit and improve with LTACH care. The enrollee 
can safely receive the care in another setting such as a skilled nursing facility. 
 
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 should only require short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care which includes vent management which will likely be chronic due to her not tolerating 
weaning. The enrollee does not require services at the LTACH that are not already available at the current 
facility.  
 There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary at this time as it would not be clinically 
advantageous. 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient can be expected to actively participate in, 
and benefit from, and intensive rehab therapy program 
whose intensity is not provided in lower levels of care. The Plan denied your request. The Plan says the 
requested care is not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an 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 records provided do not support the medical necessity for admission to 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 an 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 inpatient psychiatric care from July 20, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 20, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
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 inpatient psychiatric care from July 20, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of July 20, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond July 20, 2022, as he was not a danger to himself or others 
and did not have any delusions, auditory or visual hallucinations. 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 enrollees 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 inpatient psychiatric care from July 20, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 20, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5526) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot chew food at all. You say that 
you need these dentures, so you are no longer in pain. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 15, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a mandibular partial denture (D5526) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on March 10, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that this was denied due to exceeding the 
service limit, but this was your first visit and service for the 2022 billable year. The Plan denied your request. 
The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for 
periodontal maintenance provided on March 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are 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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has recurrent congestive heart failure (CHF). The clinical study on which Food and 
Drug Administration (FDA) approval was based showed improved clinical outcomes and decreased 
hospitalizations in enrollees in whom the CardioMEMS system was implanted, reflecting an enrollee 
population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies 
remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In 
addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in enrollee management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057 x 8) and implant 
supported crown (D6058 x 8). 
 
You asked the Plan to pre-approve the dental services. You say that you have already started the implant 
process. You say that the second part needs to be completed. You also say that you are not able to eat properly. 
The Plan denied your request. The Plan says the requested services are not listed as covered. 
 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057 x 8) 
and implant supported crown (D6058 x 8).