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 it was recommended the enrollee continues physical 
and occupational therapies and her family strongly agrees that she needs acute rehabilitation. The Plan denied 
your request. The Plan says authorization denied because criteria to IRF have not been met and the enrollee's 
needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and 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 enrollee has 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission 
. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 the SNF admission 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled 
nursing facility (SNF).
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 are currently in the hospital and right out of 
surgery. The Plan denied your request. The Plan says authorization denied because IRF is not medically 
necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 based on the documentation provided, you do not require the intensity of services 
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. Your care needs can be met at a lower 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network computed tomography (CT) scan.
You asked the Plan to pay for this service out of network. You say that you prefer to see the requested provider
for this CT scan as there are not network providers available. The Plan denied your request. The Plan says this
service could be provided in network. Maximus overturned the Plans denial. The Plan requested a reopen and
provided additional information. The Plan confirmed that prior to completion of the plan's appeal review, the
urologist office stated they spoke to you and confirmed this service could be provided within 6.1 miles from
your home, however you still wanted to go out of network
The Plan is correct in this case. 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 or pre-approved care. The provider in this case is not a network provider with
the Plan. The Plan had network providers available to render this service. We found no exception that would
require the Plan to provide coverage for these services out of network. Therefore, we decided that the Plan does
not have to pay for an out of network computed tomography (CT) scan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility admission to be provided by a 
network provider. 
 
You asked the Plan to pre-approve the skilled nursing facility admission. You say that the SNF admission is 
medically necessary. The Plan denied your request. The Plan says authorization denied because the SNF 
admission is not medically necessary and the enrollee's needs can be met at a lower level of care such as home 
with home health, or home with close follow-up with their doctor.  
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 the skilled nursing facility admission. 
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does 
not have identifiable specialized nursing service needs that require specialized skill, knowledge and judgment 
of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. The enrollee does have identifiable skilled therapy service needs that require specialized skilled 
therapy services, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. The enrollee does not require the skilled therapy services on a 
daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity in order to require 
the necessary services on an inpatient basis, in a skilled nursing facility 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 skilled nursing facility admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility admission to be provided by a network 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infuse allograft and bone marrow aspirate. 
 
You asked the Plan to pre-approve Infuse allograft and bone marrow aspirate. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Infuse allograft and bone marrow 
aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found Infuse allograft and bone marrow aspirate remain 
experimental in spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infuse allograft and bone marrow aspirate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Infuse allograft and bone marrow aspirate.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a PET scan for the enrollee.
You asked the Plan to provide coverage for a PET scan. You say that this PET scan is medically necessary for
the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was not
medical necessity but that unfortunately the required Medicare coverage criteria were not met. The Plan shows
that the enrollee had a radical proctectomy in 2009 and salvage radiotherapy in 2015. A PET scan was ordered
to determine if there were any sites of metastatic disease that cannot be seen on other types of imaging to
determine optimal treatment. However, a PET scan on February 10, 2021, showed no evidence of recurrent or
metastatic disease. Therefore, given the history of previously negative imaging less than a year previous, the
requested PET may have been beneficial and or precautionary, but would not be covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that does not cover
PET scans for precautionary measures. Therefore, we decided that the Plan does not have to provide coverage
for a PET scan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are 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 Keytruda
(Pembrolizumab). The Maximus Physician Reviewer determined that the enrollee received combination
therapy with platinum chemotherapy and will now get maintenance with Keytruda. The Plan requested a
reopen and stated that single agent use of Keytruda is not indicated for the treatment of a patient with a PD-L1
of 0%. The medical records show the enrollee is an 84-year-old woman who was diagnosed with stage IIIA
adenocarcinoma of the lung. The enrollee previously underwent a left lower lobe lobectomy, followed by 2
cycles of chemotherapy which were poorly tolerated and discontinued.
Follow-up in September 2021 documented a recurrence with bilateral pulmonary nodules. Her PD-L1 score
was 0. The Plan is correct in this case. Keytruda is FDA-approved as a single agent for the treatment of
metastatic non-small cell lung cancer whose tumors have PD-L1 expression. The enrollee's cancer in this case
does not express PD-L1. Medicare coverage criteria are 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $52.90 cost share charged for outpatient hospital lab
services provided on June 17, 2021.
You asked the Plan to waive this cost share. You say that you do not remember having this service. The Plan
denied your request. The Plan says this cost share is less than the normal cost share expectation. Maximus
administratively overturned the Plans denial for a lack of information in the case file. The Plan requested a
reopen and provided additional information which confirms these services were provided.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay a cost share for outpatient hospital lab services. 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 $52.90 cost share charged for outpatient hospital lab services provided on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre. 
 
You asked the Plan to pre-approve a Freestyle Libre. You say that the item is 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. 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 the enrollee does not 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 a Freestyle 
Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you would like reconsideration because the requested 
Retacrit is medically necessary. The Plan denied your request. The Plan says this drug is not being prescribed 
for a medically accepted indication. 
 
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 Retacrit. Our reviewer says that 
Retacrit is not medically reasonable and necessary in this case. The enrollee has not had any recen iron studies, 
B12 or folate. Our physician reviewer found the documentation does not support that Retacrit will be safe and 
effective for the enrollee. Further work-up is needed to rule out alternative causes of anemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services.
You asked the Plan to provide coverage for these services. You say that these services are medically necessary.
The Plan denied your request. The Plan says your care needs are custodial in nature which is not covered by
Medicare. 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 Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
The medical records show no daily skilled nursing facility services were required. In addition, the records show
the services required were to assist with activities of daily living and were not intended or thought to greatly
improve your level of function. 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 provide coverage for
skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for varicose vein treatment for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are 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 varicose vein
treatment. The Maximus Physician Reviewer determined that the documentation supports the medical necessity
of the treatments in question. The Plan requested a reopen and argues that LCD criteria does not have an
exception for bypassing conservative treatment in the event of bleeding. The Plan also notes that the enrollee's
vein measurements are up to 8mm, and in the area of the varicosities the veins are 4-5mm, which does not meet
the definition of varicose veins (12mm for sclerotherapy). The Plan is correct in this case. The case file does
not contain sufficient documentation supporting that the enrollee had failed 3 months of conservative therapy.
The coverage criteria specifically state ERFA and laser ablation are covered only for the treatment of
symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3
months of conservative therapy. Based on the medical records, the Medicare coverage criteria are 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 this treatment have not been met. Therefore, we decided that the Plan does not
have to pre-approve varicose vein treatment for the enrollee.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services beyond March 25, 2022. 
 
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration 
because the requested home health services are medically necessary. The Plan denied your request. The Plan 
says that the enrollee does not meet Medicare criteria for coverage of the continued home health services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer 
says that the enrollee meets criteria for the continuation of home health services. Our physician reviewer found 
skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve 
the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level 
of function and/or prevent deterioration. 
 
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 home health services have been met. Therefore, we decided that the Plan has 
to pre-approve home health services beyond March 25, 2022.  
 
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 pneumatic compressor and segmental pneumatic 
appliance for use with pneumatic compressor, full leg to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance for use with 
pneumatic compressor, full leg to be provided by an OON provider. You say that the services are necessary. 
The Plan denied your request. The Plan says there are in-network providers that are able to provide these 
services. Therefore, coverage criteria have not been met. 
 
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 
a pneumatic compressor and segmental pneumatic appliance for use with pneumatic compressor, full leg to be 
provided by an out-of-network (OON) provider.