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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 that you were admitted for congestive heart failure, transaminitis and lactic acidosis. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 20, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan presented documentation to
show that this claim denied because the provider billed this service inappropriately. The Plan submitted
specific documentation of only 15 drug classes counted from the laboratory results received. The Plan states
there is another more appropriate code less than 22 classes billed, and the provider billed the wrong code.
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 codes. In this case, the Plan has
provided lab results to show less than 22 classes were tested, meaning this claim was not coded appropriately.
Medicare uses another code for testing resulting in less than 22 classes of drugs. Therefore, we decided that the
Plan does not have to pay for drug testing provided to the enrollee on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 30, 2021. 
 
You asked the Plan to pay for 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, fluorescence in situ hybridization (FISH) testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve the tub. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 walk-in bathtub.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vyvgart. 
 
You asked the Plan to pre-approve Vyvgart. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested use is not supported. 
 
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 Vyvgart. Our reviewer says that the 
requested use of Vyvgart is medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of myasthenia gravis, anti-acetylcholine receptor antibody positive.  The Food and 
Drug Administration has stated that the requested drug is indicated for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyvgart have been met. Therefore, we decided that the Plan has to pre-approve 
Vyvgart.  
 
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 pre-approve a heavy-duty hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that this item is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds. 
 
We looked at the file and Medicare rules. In this case, the documentation lists your weight as less than the 
required 350 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy-duty 
hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty 
hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on November 2, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the physician services. You say that the provider is in the Plan's network. The 
Plan denied your request. The Plan says the provider is not in the Plan's network. 
 
  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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 physician services provided on November 2, 
2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 32 one-way routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request exceeds the maximum transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 32 one-way routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a second opinion. 
 
You asked the Plan to pre-approve the referral. You say that this is the doctor who performed the cataract 
surgery years ago. The Plan denied your request. The Plan says there are network providers available. 
 
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 
an out-of-network referral for a second opinion.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zilretta (J3304, 20610). 
 
You asked the Plan to pre-approve Zilretta. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 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 Zilretta. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drug Triamcinolone before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug. There is no documentation provided indicating that the 
Plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Zilretta (J3304, 20610).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imbruvica tablets. 
 
You asked the Plan to pre-approve Imbruvica tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Imbruvica tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Imbruvica tablets.  
 
Benefits for Imbruvica tablets 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: Unfavorable

 
We decided that the Plan does not have to pre-approve An oral device for CPAP to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve An oral device for CPAP. You say that you had your required follow up 
appointment. The Plan denied your request. The Plan says the enrollee was asked to see an in-network provider 
but saw an OON provider. 
 
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 
An oral device for CPAP to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tepezza. 
 
You asked the Plan to pre-approve Tepezza. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Tepezza. Our reviewer says that the 
requirements for coverage have not been met. Our physician reviewer found the Plan requires a trial of 
systemic steroids for 4 weeks before they will approve the requested drug. The provided records do not indicate 
that the enrollee has tried and failed systemic steroids. The records also do not indicate systemic steroids likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tepezza.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 8, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan
presented documentation to show that this claim denied because the provider billed this service inappropriately.
The Plan submitted specific documentation of only 18 drug classes counted from the laboratory results
received. Code G0483 is only used when 22 or more classes were tested. The Plan states there is another more
appropriate code for the services provided and the provider billed the wrong code.
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 codes. In this case, the Plan has
provided lab results to show less than 22 classes were tested, meaning this claim was not coded appropriately.
Medicare uses another code for testing resulting in less than 22 classes of drugs. Therefore, we decided that the
Plan does not have to pay for drug testing provided to the enrollee on June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Outpatient Therapies to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Outpatient Therapies. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received by 92 available in-network providers. 
 
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 
Outpatient Therapies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional chiropractic treatment. 
 
You asked the Plan to pre-approve additional chiropractic treatment. You say that you have arthritis and limited 
movement, and you cannot exercise due to osteoarthritis. The Plan denied your request. The Plan says that 7 
additional visits are not reasonable and necessary. The Plan agreed to pre-approve 6 additional visits. 
 
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. Specifically, the Plan has not provided us with the required medical records. 
Therefore, we decided that the Plan has to pre-approve additional chiropractic treatment.  
 
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 pre-approve a raised toilet seat and incontinence supplies. 
 
You asked the Plan to pre-approve a raised toilet seat and incontinence supplies . The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. 
 
While a raised toilet seat may be appropriate for A. Sampson, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat and incontinence 
supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy) and a mastopexy. 
 
You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy) and a 
mastopexy. The Plan denied your request. The Plan says excision, excessive skin and subcutaneous tissue 
(includes lipectomy) and a mastopexy are solely for cosmetic purposes and does not meet medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of excision, excessive skin and 
subcutaneous tissue (includes lipectomy) and a mastopexy have been met. You have not provided medical 
records to confirm Medicare coverage criteria. Therefore, we decided that the Plan does not have to pre-
approve excision, excessive skin and subcutaneous tissue (includes lipectomy) and a mastopexy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
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 self-administered drugs are not covered. 
 
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 Xifaxan.  
 
 
 Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.