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

 
We decided that the Plan does not have to pre-approve Incruse Ellipta. 
 
You asked the Plan to pre-approve Incruse Ellipta. You say that the enrollee has tried and failed Spiriva and 
Anoro. You also say that the requested drug has helped 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 Incruse Ellipta.  
 Benefits for Incruse Ellipta 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that your health requires you to be in rehabilitation for 
care. The Plan denied your request. The Plan says your records do not show that you need this type of care. 
 
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 do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 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 pay for the shoulder arthroscopy (29819), provided on September 
20, 2022. 
 
You asked the Plan to pay for the shoulder arthroscopy. You say that the service was medically necessary. The 
Plan denied your request. The Plan says codes with an assistant at surgery indicator of 1, assistant surgeon 
services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29819. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the 
shoulder arthroscopy (29819), provided on September 20, 2022.
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 you are requesting LTACH services 
because the enrollee cannot be optimally restored at any other level of care. The Plan denied your request. The 
Plan says the enrollee does not meet all the requirements for an LTACH admission. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. 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 Plan. 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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided to the enrollee on January 26, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says this was a duplicate claim. Maximus overturned the Plans denial for insufficient claim
information in the case file. The Plan requested a reopen and provided additional claim information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, we find that Claim A is a duplicate submission for a previous payment
made by the Plan on February 11, 2022. Based on this information, we decided that Medicare rules for payment
of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical
services provided to the enrollee on January 26, 2022, and billed under Claim A.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for vertical bite dental services provided on June 13, 2022.
You asked the Plan to pay for these services. You say that these x-rays should be covered by the Plan. The Plan
denied your request. The Plan says vertical bite x-rays are not a covered service. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract criteria.
The Plan is correct in this case. 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.
The Plans contract is specific about what dental services are covered. Vertical bite x-rays are not listed.
Therefore, we decided that the Plan does not have to pay for vertical bite dental services provided to the
enrollee on June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the member does not need this item. Our physician reviewer found the Life2000 device is not a true 
ventilator, because it is not capable of providing full ventilatory support.  Its primary intended use is during 
activity, and not to treat chronic carbon dioxide (CO2) retention during sleep.  There is inadequate evidence of 
its safety and effectiveness in the treatment of COPD. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. The Plan denied your request. The Plan says that the 
coverage criteria has not been 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen. 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. 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 Hydrocodone-
Acetaminophen.  
 Benefits for Hydrocodone-Acetaminophen 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Kit sensor. 
 
You asked the Plan to pre-approve a Freestyle Kit sensor. The Plan denied your request. The Plan says that the 
enrollee does not require insulin three or more times daily. 
 
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 documentation provided only included Durable Medical Equipment Orders. 
There were no medical records provided from the prescribing physician showing what medications the enrollee 
takes and whether or not the enrollee uses insulin. The appellant is a participating provider and considered an 
agent of the Plan. The Plan is responsible to provide us with any documentation required for us to make a 
determination regarding their denial. Without medical records from the Plans participating provider we are 
unable to substantiate their denial reason or review whether the enrollee meets the criteria for coverage of a 
CGM. Therefore, we decided that the Plan has to pre-approve a Freestyle Kit sensor.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99335) provided on September 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the physician relies on the 
facility staff to obtain the necessary authorizations. You also say that the the service was rendered to the 
enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit (99335) provided on September 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate. 
 
You asked the Plan to pre-approve methotrexate. You say that the enrollee has been on this drug for several 
years. You also say that the enrollees dose may need to be adjusted soon. 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 methotrexate.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient admission provided to the enrollee from September 22, 2021,
to September 24, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was medically
necessary for the enrollee. The Plan denied your request. The Plan says that the required criteria for inpatient
care, based on the guidelines followed by the Plan, were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and additional clarification on the decision.
A Maximus physician reviewer looked at the case file. At issue is coverage for inpatient admission. Our
reviewer says that the medical records show the enrollee was a then, 73-year-old female with comorbidities of
coronary artery bypass graft (CABG) with three stents, is on anticoagulants), cerebral vascular accident (CVA),
hypertension, and history of kidney transplant. The enrollee presented to the Emergency Department (ED) on
September 22,2021, following a mechanical fall from her wheelchair. She fell back striking her head. Vital
signs: Respiratory Rate 13-19, Heart Rate 51, Average Systolic BP 156. Physical examination: No loss of
consciousness or neuro deficits, PERRLA, GCS15. She was given computed tomography of the head, spine,
abdomen and pelvis. All were negative for acute findings. Progress notes indicated the patient received 1000
ml intravenous fluid bolus, followed by fluid sat 100 ml per hour. Norco was provided for pain, Gabapentin
300mg, Lasix 40mg, and Cyclosporine (to prevent kidney rejection). The enrollee was on anticoagulants, and
there were concerns for a delayed bleed. It is the finding this reviewer that the record shows that at the time of
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care
(including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for inpatient admission provided to the enrollee from September 22, 2021, to September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a breast prosthesis and bra provided on 
September 21, 2022. 
 
You asked the Plan to waive the coinsurance for the breast prosthesis and bra. You say that you were not told 
there would be a charge for these items. 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 20% 
coinsurance for prosthetic devices.  
 
You have been asked to pay $48.52, which is 20% coinsurance of the allowed amount for the breast prosthesis 
($242.61 allowed amount x 20% coinsurance = $48.52). You have also been asked to pay $38.82, which is 
20% coinsurance of the allowed amount for the bra prosthesis ($194.10 allowed amount x 20% coinsurance = 
$38.82). You have been asked to pay a total of $87.34 ($48.52 coinsurance + $38.82 coinsurance = $87.34). 
These items/services fall within the prosthetic devices and related 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 coinsurance for a breast prosthesis and bra provided on September 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary for you to gain back 
strength and mobility. The Plan denied your request. The Plan says the records do not show that you require 
daily nursing or skilled therapy. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an audiology office visit provided on 
November 7, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you never made an appointment 
with this provider and should not be charged. 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 $50 
copayment, for specialty care physician/practitioner services including doctors office visits.  
 
You have been asked to pay a $50 copayment for an office visit. This item/service falls within the specialty 
care physician/practitioner services including doctors office visits 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 an audiology office visit provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 31,
2022 and billed under code 97112.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans
denial for insufficient information in the case file to support the Plans denial. The Plan requested a reopen and
provided additional clarification regarding their denial.
The Plan demonstrated that they approved payment for codes G0283, J3420 and J3475. The Plan noted that
code 97112 could not be paid due to a lack of medical records to support the services billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code and submit medical records
to substantiate the Plans denial. Code 97112 is described as Neuromuscular Re-education which includes a
therapeutic procedure on 1 or more areas, each 15 minutes in length; neuromuscular re-education of movement,
balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
We reviewed the medical records in this case file. Based on the medical records provided, we are unable to
confirm that these services were provided to the enrollee. Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the
enrollee on March 31, 2022, and billed under code 97112.