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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. 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 power mobility devices are covered when specific 
criteria are met. 
 
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 group 3 power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found provided records 
document your mobility limitation is due to both your weakness with a history of stroke and due to your 
amputations. Records from your treating medical provider, however, do not support that you are at high risk for 
development of a pressure ulcer and is unable to perform a functional weight shift or you utilize intermittent 
catheterization for bladder management, or the power seating system is needed to manage increased tone or 
spasticity. Thus, although records support the need for a power wheelchair, the provided records do not support 
that you meet criteria for the requested group 3 power wheelchair with single power option (power tilt). 
 
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 group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says this is not medically necessary; the enrollees needs can be met with 
intermittent physical and occupational three to four times per week. The enrollees needs are largely custodial 
currently. 
 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 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 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the criteria for 
admission to the acute inpatient rehabilitation 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 the clinical documentation shows that the enrollee has functional impairments 
however there are no documented complex functional deficits that would require intense therapy or 
interdisciplinary team management.  The documentation states that the enrollee has active medical comorbidities in the appeal letter, but there are 
none specified. IRF criteria has not been 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat TFESI is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not reveal 50 
percent sustained improvement in pain relief and/or improvement in function measured from baseline using 
same scale for at least three months from the prior injection. The requested repeat injection is therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on March 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and are asking the 
plan to adjust the claim to be paid. The Plan denied your request. The Plan says for services to be covered they 
must be medically necessary services, supplies, or drugs that are needed for the prevention, diagnosis, or 
treatment of your medical condition and meet accepted standards of medical practice. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 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 laboratory services have been met. The 
records submitted show no evidence of planned chemotherapy or evidence about other testing or any actual 
medical record of the enrollee's condition. The submitted record is a requisition not medical records. Therefore, 
we decided that the Plan does not have to pay for laboratory services (81455) provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you want to avoid back surgery. The Plan 
denied your request. The Plan says the services are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for doctor visit provided on April 22, 2022. 
 
You asked the Plan to waive the copayment for doctor visit. You say that you refuse to pay the copayment. 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 $40 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $40 copayment for doctor visit. This item/service falls within the 
physician/practitioner services, including doctor's 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 doctor visit provided on April 22, 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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says the intensity and frequency of care that is required can be met at a 
lower level of care. The Plan says that there is no documentation of daily intense and complex care needs 
which would require a SNF level of care. 
 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 there are no identifiable skilled nursing or skilled therapy service needs. The enrollee 
does not meet the severity of illness or intensity of service criteria for 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye prosthetics provided on July 12, 2022. 
 
You asked the Plan to pay for eye prosthetics. You say that you should be reimbursed for the entire cost besides 
your coinsurance. The Plan denied your request. The Plan says the Medicare allowed amount has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of eye prosthetics have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare Allowed Amount for this service. A Medicare provider should accept the Medicare Allowed Amount 
as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for eye prosthetics 
provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI) services. 
 
You asked the Plan to pre-approve Special Supplemental Benefits for the Chronically Ill (SSBCI) services. 
You say that you would like to request reconsideration of the denied authorization. The Plan denied your 
request. The Plan says the services requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Special Supplemental Benefits for the Chronically Ill (SSBCI) services have not been met. 
Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of 
Coverage. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental Benefits for 
the Chronically Ill (SSBCI) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 28, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that if these drugs were self-administered, 
they were yours and you do not owe anything. The Plan denied your request. The Plan says self-administered 
drugs are not covered while you are in the hospital. 
 
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 pay for the self-administered drugs 
provided on May 28, 2022.  
 
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve Entresto. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of your prescription drug plan. 
 
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 Entresto.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate maxillary denture (D5130). 
 
You asked the Plan to pre-approve an immediate denture. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 4, 2017. Therefore, 
we decided that the Plan does not have to pre-approve an immediate maxillary denture (D5130).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urinalysis. 
 
You asked the Plan to pre-approve the testing. You say that you thought this would be covered since it was 
ordered by the doctor. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee received a urine test (urinalysis) at the urgent care center with complaint of dysuria and 
frequent urination on 9/2/22. She was given antibiotics, but the culture suggested no infection and symptoms 
resolved. However, a doctor's order was not provided from the urgent care center for urinalysis or whatever 
testing was actually ordered and performed on 9/2/22 to confirm. Therefore, without documentation provided 
from the urgent care center, this request for urine testing will be considered not medically necessary at this 
time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve urinalysis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (83789) provided June 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says referring provider records were not submitted to determine medical 
necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the lab services have been met. In this 
case medical records from the referring provider were needed to determine medical necessity. The Plan made 
several attempts to request this information, but the required records was not submitted. Without these records 
we are unable determine if the requested lab services were medically necessary. Therefore, we decided that the 
Plan does not have to pay for the lab services (83789) provided June 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Polatuzumab (Polivy) for the enrollee.
You asked the Plan to pre-approve this request. You say that this drug 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 Polatuzumab (Polivy). The Maximus Physician Reviewer determined that Polatuzumab (Polivy) is supported by major drug compendia. The Plan requested a reopen and argues that Maximus did not apply the correct coverage criteria. The medical records show the enrollee has a history of diffuse large B-cell lymphoma, and presumed stage 1 non-small cell lung cancer. The enrollee now appears to have a second diffuse large B-cell lymphoma. The enrollee has significant cardiac disease, and prior treatment with Anthracycline, making treatment options limited. The Plan is correct in this case. There is insufficient evidence to support the requested regimen in this case (Polatuzumab, Cyclophosphosphamide, Etoposide, Vincristine, Prednisone, and Rituximab).
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 request have not been met. Therefore, we decided that the Plan does not have to pre-approve Polatuzumab (Polivy) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia. 
 
You asked the Plan to pre-approve Cimzia. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
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 Cimzia.  
 
Benefits for Cimzia 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 orthopedic footwear inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic footwear inserts.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on May 19, 2022.