Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose 
continuous monitor system (K0554) supply allowance for CGM (K0553). 
 
You asked the Plan to pre-approve Freestyle Libre 2. You say that the amount of insulin the enrollee injects 
varies. Using the Freestyle Libre system will help the enrollee check her level accurately. The Plan denied your 
request. The Plan says that the records do not support that the enrollee meets all of the criteria. The Plan says a 
standard home blood glucose monitor appears to be appropriate. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 Freestyle Libre 2. Our reviewer says 
that the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is status post kidney transplant. She takes Novolog 2-3x a day and varies the doses. 
The letter written by the provider on July 5, 2022 implies that the enrollee is varying the doses of Novolog 
according to the blood glucose level and perhaps food intake. She is taking Tacro and Prednisone which can 
impact blood glucose. The July 5, 2022 letter implies that the enrollee is using a sliding scale of Novolog 
insulin 3x a day and this therefore qualifies her for a CGM. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre 2 have been met. Therefore, we decided that the Plan has to pre-
approve receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) 
supply allowance for CGM (K0553).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued inpatient mental health care for the
enrollee after March 4, 2022.
You asked the Plan to provide coverage for this service. You say that at the time of the appeal, continued
treatment was 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 apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued acute
inpatient psychiatric hospitalization.
The Maximus Physician Reviewer determined that it did appear medically necessary and reasonable to have
psychiatric care provided at the acute inpatient level of care rather than a lower level of care as although she did
not have dangerousness to self or others, she was found to be psychotic. The Plan's denial of inpatient
psychiatric services appears inappropriate. The Plan requested a reopen and stated that it is not clear that the
reviewer realized the issue being appealed was the continued hospitalization, and not the original admission.
The medical records show the enrollee had a long history of chronic psychotic disorder (schizoaffective
disorder, bipolar type, and Schizophrenia, unspecified). The enrollee was admitted to the hospital on February
10, 2022. On March 4, 2022, it is documented that the enrollee "has been evaluated by rehab for physical
therapy and arrangements are being made for transfer this evening." On March 6, 2022, it is noted that
coordination was taking place with the rehab facility for physical therapy for transportation. On March 7, 2022,
and March 8, 2022, it is documented that the enrollee "remains awaiting transfer to physical rehab."
Our Medical Director has determined that the Plan is correct. The issue of continued inpatient psychiatric
hospitalization was not addressed 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 service have not been met.
Therefore, we decided that the Plan does not have to provide coverage for continued inpatient mental health
care for the enrollee after March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says they have in-network providers that can provide the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the 
ophthalmology services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-home IV infusion of Panzyga 30GM/300ML solution 
(CPT code J1599). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Medicare medical benefit provides limited coverage for outpatient prescription 
drugs. The Plan states it only covers certain types of drugs under the medical benefit that the enrollee takes at 
home when used for specific medical conditions. The Plan states the requested drug is not of a type and/or used 
for a condition that is covered under the medical benefit. 
 
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 medication. Our physician reviewer 
found the record indicates that the enrollee has Lambert Eaton syndrome. The noted diagnosis is not a 
diagnosis that is covered under the LCD. 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve in-home IV infusion of Panzyga 30GM/300ML solution (CPT code J1599).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayments charged for specialist visits from July 2, 2021, to November 16, 2021.
You asked the Plan to waive these copayments. You say that you should not have to pay these copayments. The Plan denied your request. The Plan says these copayments were charged based on the Plan contract agreement. Maximus administratively overturned the Plans denial because a Plan contract had not been submitted for review. The Plan requested a reopen and provided the required contract.
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. Your contract with the Plan clearly says that you must pay $400 copayment for each specialist visit. 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 $40 copayments charged for specialist visits from July 2, 2021, to November 16, 2021.
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 has a better chance 
optimizing to a higher level of function at an LTACH than at a lower level of care. The Plan denied your 
request. The Plan says criteria for admission to the LTACH have 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 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 are medically stable and do not need PM&R physician's close supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. You do not need 3 hours a day x 5 days a week of therapies. You will not tolerate the 
intensity of IRF with profound deconditioning with your chronic comorbid conditions and will not make a 
significant functional progress in a predicted period of time. Your rehab needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing 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 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 the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are needed for the enrollee to regain 
their maximum function. The Plan denied your request. The Plan says the records do not show a need for an 
intensive program with a team of health care professionals and doctors that specialize in complex medical 
needs as well as rehabilitation. The enrollee's therapy can be received at an alternate level of care such as a 
skilled nursing facility. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. 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 medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided 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 the IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare guidelines 
for LTACH admission. The Plan denied your request. The Plan says the enrollee does not have a complex 
medical condition that requires frequent care and services, with daily doctor visits. The enrollee does not have 
wound care that requires complex nursing services with daily doctor visits. The enrollee's doctor expects that 
they will require at least a 25 day stay in a facility that can meet their needs. The services the enrollee needs 
could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, outpatient 
setting or home care. 
 
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 he/she is currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health 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 the LTACH 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 a LTACH admission is medically 
necessary The Plan denied your request. The Plan says the medical criteria for a 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 that the Plan does not have to pre-approve a replacement group 3 power wheelchair (PWC) with 
multiple power options and related accessories. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that this replacement wheelchair 
is medically reasonable and necessary. The Plan denied your request. The Plan says the notes provided do not 
show why current group 3 power wheelchair you have cannot be modified to meet your needs. 
 
The Plan follows Medicare rules. Medicare rules say that during the reasonable useful lifetime of an item, 
which can be no less than five years, Medicare will not cover replacement due to wear.  
 
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 replacement power wheelchair. Our 
reviewer says that the requested replacement power wheelchair is not medically reasonable and necessary. Our 
physician reviewer found on April 4, 2022, a comprehensive mobility evaluation was performed. In that 
evaluation it is stated that your current group 3 PWC is 8 years old, requires major repairs, and cannot be 
repaired due to its age. Elsewhere it is stated that your wheelchair is 6 years old and needs updating. It is also 
stated in the case file that the enrollee has a power chair thats 5 years old. However, it is documented that a group 3 standard power wheelchair with a single power option (K0856) was approved for you on November 1, 
2017. The documentation supports that the enrollees PWC is less than 5 years old. The available 
documentation does not support the assertion that the enrollees current PWC cannot be repaired due to its age 
as would be required during the reasonable useful lifetime period. The requested replacement would exceed 
your needs at this time.  
 
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 replacement power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a replacement group 3 power wheelchair (PWC) with multiple power 
options and related accessories.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing services. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. The requested services are custodial in nature. 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 private duty nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant procedure (D6199), deep sedation/general 
anesthesia (D9222 and D9223), and therapeutic parenteral drugs (D9612) provided on April 7, 2022 by a 
Medicare opt out provider. 
 
You asked the Plan to pay for the implant procedure, deep sedation/general anesthesia, and therapeutic 
parenteral drugs. You say that Medicare is obligated to partially cover the cost of the surgical procedure. The 
Plan denied your request. The Plan says these services were performed by a provider who opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
implant procedure (D6199), deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral 
drugs (D9612) provided on April 7, 2022 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of lateral exostosis (maxilla or mandible) 
(D7471) excision procedures on the head (21031) moderate sedation (99153, 99158). 
 
You asked the Plan to pre-approve exostosis removal. You say that you believe surgery on your dental tori is a 
medical necessity because of how large they have grown. The Plan denied your request. The Plan says the 
requested surgery is for cosmetic reasons and is not covered. 
 
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 
removal of lateral exostosis (maxilla or mandible) (D7471) excision procedures on the head (21031) moderate 
sedation (99153, 99158).