Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that an IRF admission does not meet the Medicare guidelines. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that based on review of the available records, the enrollee with cardiac debility and multiple medical 
problems meets the Medicare coverage criteria for an IRF admission. The enrollee is not completely medically 
stable and needs, medical monitoring by a physical medicine and rehabilitation physician (PM&R) with close 
supervision 3 times per week (at a minimum) for the ongoing management of active or acute exacerbations of 
chronic medical conditions. The enrollee has rehabilitation nursing needs for bladder care and education of 
medications post-op. The enrollee needs 3 hours a day x 5 days a week of therapies with multidisciplinary 
approach in an IRF. The enrollee has potential for significant functional progress in physical therapy (PT) and 
occupational therapy (OT) in the expected 10 days. The documents as of January 16, 2023 supported medical 
necessity for admission to an IRF. The enrollee has acute medical complexity and acute rehabilitation nursing 
needs for an IRF admission. The enrollee would benefit from PT and OT and his rehabilitation needs cannot be 
safely met in an alternate and low intensity setting such as in a skilled nursing facility. The enrollee needs an 
IRF admission. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630) and placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site 
(D7922). 
 
You asked the Plan to pre-approve the drugs dispensed for home use and intra-socket biological dressing. You 
say that you are in excruciating pain and need these services. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
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 drugs or medicaments dispensed in the office for home use (D9630) and placement of intra-socket biological 
dressing to aid in hemostasis or clot stabilization, per site (D7922).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care.
You asked the Plan to pay for SNF care. You say that these services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. Maximus overturned the Plans denial. The Plan requested a reopen and argued an incorrect review was completed. The medical records show the enrollee had several health conditions. The enrollee was brought to the emergency room on February 18, 2021, with confusion. Respiratory status worsened and she was subsequently intubated. She was stable for discharge on February 27, 2021. Based on the records provided, the documentation does not support that the enrollee required skilled nursing services. The documentation does not support that it was medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a skilled nursing facility setting. Medicare coverage criteria were not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the ease of the device could aid in 
treatment. The Plan denied your request. The Plan says you are not on insulin injections. 
 
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 does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 3 additional home health visits for the enrollee.
You asked the Plan to provide coverage for 3 home health visits. We note the original request was for 12, of which the Plan approved 9. This left 3 visits remaining under appeal. You say that at the time of the appeal these visits were medically necessary. The Plan denied your request. The Plan says the enrollee had returned to baseline and the three visits not approved were not necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated the Maximus did not apply the correct criteria.
The Plan is correct in this case. 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. Based on the medical records provided, the enrollees care needs could have been achieved within the 9 visits approved by the Plan due to the enrollee being at baseline at the time of the appeal. Medicare rules for coverage of this request were not met. Therefore, we decided that the Plan does not have to provide coverage for 3 additional home health visits for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extra spinal chiropractic treatment (98943) and the electrical stimulation (00283) provided on May 25, 2022
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says extra spinal chiropractic treatment and electrical stimulation are not covered when administered by a chiropractor by Medicare or the Plan. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Proof of prior paid visits was not required as this was not the issue. The issue was payment for non-covered services in a chiropractic setting. Therefore, we decided that the Plan does not have to pay for extra spinal chiropractic treatment (98943) and the electrical stimulation (00283) provided on May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service October 12, 
2022. 
 You asked the Plan to pay for procedure code 71250. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 71250 is bundled into payment for 
code 71275. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71250 
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71250 billed for date of service October 12, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675). 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says these items were being used outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0673, E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1845).

You asked the Plan to pre-approve a knee orthosis. 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 follows Medicare rules. Medicare rules say that a knee flexion contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 0 degrees extension or greater (i.e., hyperextension) by passive range of motion.

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 knee orthosis. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has significant osteoarthritis of both knee joints as demonstrated by radiological imaging and the clinical documentation. He
has been receiving injections with viscosupplementation since he does not want knee arthroplasty. He has not recently had surgery or injury and there is no indication of significant instability on the physical examination. The guidelines require that a knee orthosis is considered medically necessary with evidence of trauma, recent surgery or instability and unloading for knee osteoarthritis is not an indication. Therefore, the hinged medial unloader orthosis cannot be considered medically necessary.

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399) 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (E1399)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure device (A4670). 
 
You asked the Plan to pre-approve an automatic blood pressure device. You say that here are the required 
documents which prove medical necessity for the equipment. Please find the attached documents and process 
the authorization towards approval. The Plan denied your request. The Plan says this item is not covered by 
Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure device (A4670).
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 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. 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 clinical documentation shows that the enrollee has active medical comorbidities 
however, there are no specified complex functional deficits. Thus, the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdualag.

You asked the Plan to pre-approve Opdualag. You say that the requested Opdualag is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Keytruda or Opdivo as monotherapy; OR Opdivo in combination with Yervoy first.

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 Opdualag. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has melanoma. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdualag have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdualag.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lutetium Lu 177 Vipivotide Tetraxetan, also called 
Pluvicto (A9607). 
 
You asked the Plan to pre-approve a drug, Pluvicto. You say that you have aggressive prostate cancer and 
Parkinson's disease. You are supposed to have this injection every 6 weeks and are due for an injection. You 
have never received your first one because of the denial. The Plan denied your request. The Plan says the use of 
Pluvicto for metastatic castration-resistant prostate cancer with unknown PSMA status and no previous taxane-
based chemotherapy is not FDA approved or listed in the Medicare approved sources. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the requested drug is not FDA approved or 
listed as a covered drug for Medicare. Based on this information, we decided that Medicare rules for coverage 
of a drug have not been met. 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pre-approve Lutetium Lu 177 Vipivotide Tetraxetan, also 
called Pluvicto (A9607).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right and left heart catheterization. 
 
You asked the Plan to pre-approve right and left heart catheterization. You say that the requested right and left 
heart catheterization is medically necessary. The Plan denied your request. The Plan says the requested right 
and left heart catheterization is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve right and left heart catheterization. Our 
reviewer says that the requested right and left heart catheterization is not medically necessary. Our physician 
reviewer found the record indicates that the enrollee has stable angina. The record indicates that the enrollee last had a stress test in 2019. The record provided is insufficient to establish the medical necessity of the 
requested service at this time. 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. 
The requested service is not 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 right and left heart catheterization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right and left heart catheterization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring 
an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested inpatient admission for the approved 
total shoulder arthroplasty, in this case, is not medically reasonable or necessary. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.