Persius/hicric huggingface dataset:
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 admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the documentation
provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented
skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can
be provided 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 admission to a SNF 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you would benefit from a SNF stay. The Plan denied your request. The Plan says that your needs are custodial.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin and Paclitaxel to be added with
Pembrolizumab treatment for the enrollee.
You asked the Plan to pre-approve Carboplatin and Paclitaxel. You say that this drug 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 applied the incorrect criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Carboplatin and
Paclitaxel. The Maximus Physician Reviewer determined that the requested drugs are medically necessary for
the enrollee's medical condition. Our physician reviewer found the enrollee has stage IV non-small cell lung
cancer. In this case, the requested drugs are not approved by the FDA for the enrollee's condition. However,
there is support in the Medicare-approved Compendia for their use in non-small cell lung cancer. In addition,
these drugs can be considered safe and effective and otherwise reasonable and necessary for this enrollee. The
plan argues that there is no established evidence to support the use of Pembrolizumab with carboplatin/nabpaclitaxel
for metastatic non-small cell lung cancer after prior disease progression on maintenance
pembrolizumab.
The medical records show the diagnosis is adenocarcinoma of the lung diagnosed in 2019. The enrollee had
been doing extremely well on Keytruda. Imaging on June 5, 2021 demonstrated multiple new metabolically
active pleural metastases and metabolically active lymph nodes. The request was to add Carboplatin and
Paclitaxel to Pembrolizumab for metastatic non-small cell lung cancer progressing on Pembrolizumab.
The Plan is correct in this case. While there is support in the Medicare-approved Compendia for the use of
Carboplatin and Paclitaxel in treatment of non-small cell lung cancer, support for their use with
Pembrolizumab is lacking. Therefore, 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 Carboplatin and Paclitaxel have not been met. Therefore, we decided that the
Plan does not have to pre-approve Carboplatin and Paclitaxel to be added with Pembrolizumab treatment for
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator.
You asked the Plan to pre-approve an auricular stimulator. You say that the clinical documentation provided
supports the medical necessity of the service in dispute. The Plan denied your request. The Plan says the
service being requested is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation is not a
covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of
reasonable and necessary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular
stimulator.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve power elevating leg rests (E1012).
You asked the Plan to pre-approve power elevating leg rests. You say that this equipment is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a power elevating leg rest is subject to the criteria listed 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 power elevating leg rests. Our reviewer says that the requested item is medically and reasonable. Our physician reviewer found based on the medical records provided there is documentation that the enrollee meets the coverage criteria for the requested center mount power elevating leg rests (E1012). A note from an occupational therapist dated June 16, 2021, documents bilateral lower extremity edema on examination of the enrollee thus meeting criteria for the power elevating leg rests. The occupational therapist attested to no relationship with the durable medical equipment vendor. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power elevating leg rests have been met. Therefore, we decided that the Plan does not have to pre-approve power elevating leg rests (E1012).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Contour Next glucose meter.
You asked the Plan to pre-approve the requested meter. You say that the device uses less blood. The Plan
denied your request. The Plan says the requested device is not a preferred meter.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as
preferred. The requested brand of glucose meters in this case is not a covered brand with the Plan. The Plan has preferred
products that can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these non-preferred items. Therefore, we decided that the Plan does not have to preapprove
a Contour Next glucose meter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left reverse total shoulder arthroplasty (23472).
You asked the Plan to pre-approve the left reverse total shoulder arthroplasty. You say that the requested service 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 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 the left reverse total shoulder arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for reverse shoulder arthroplasty not met. There is no documentation of rotator cuff tear needed for reverse arthroplasty. 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 left reverse total shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve the left reverse total shoulder arthroplasty (23472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of extra bone in the roof of the mouth,
general anesthetic, and drug injection services represented by codes D7473, D9222, D9223, and D9612.
You asked the Plan to pre-approve dental services represented by codes D7473, D9222, D9223, and D9612.
You say that you need the requested procedures performed due to pain, sensitivity and breaking teeth. The Plan
denied your request. The Plan says the services being requested are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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 the
removal of extra bone in the roof of the mouth, general anesthetic, and drug injection services represented by
codes D7473, D9222, D9223, and D9612.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eye surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve eye surgery 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 eye surgery to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the record does not show that you require daily skilled nursing or
skilled therapy in a SNF setting.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that 8 additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says 8 additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 8 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 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 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
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 enrollee would benefit from IRF care. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
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 Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for chest pain and coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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.reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.
You asked the Plan to pre-approve Botox. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is not record of medical reasons that prevent the enrollee from using one of these preferred drugs.
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 Botox. Our reviewer says that Botox is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Dysport or Xeomin. There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Botox. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox for the enrollee.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve services of a home health aide (HHA) (G0156).
You asked the Plan to pre-approve the home health services. You say that the requested service is medically necessary. The Plan denied your request. The Plan says that you did not meet Medicare criteria for approval.
The Plan must follow Medicare rules. The rules say that home health aide (HHA) services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 HHA services are medically reasonable and necessary for you. Our physician reviewer found that the Plan argued that the requested HHA services are not being used to help with nursing services in the home. The home health nursing certification and plan of care in the provided records clearly states that part of the plan of care is that you will receive safe and effective personal care during this episode of care. Our reviewer found that there is documentation that the HHA services are reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. Our physician reviewer also found that the records document you have poor endurance and physical limitations which limit your ability to safely provide self-care and the home health aide services would benefit you in this respect. 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 services of a home health aide (HHA) (G0156).
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 an oxygen concentrator.
You asked the Plan to pre-approve the oxygen concentrator. You say that you haven't had new testing done because your pulmonologist is too far away. The Plan denied your request. The Plan says you do not meet criteria.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our 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 oxygen concentrator. Our reviewer says that the service is not approved. Our reviewer found approval for home oxygen is contingent on a qualifying blood gas study. You have not had a recent one. 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 oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on November 3, 2020.
You asked the Plan to pay for the acute inpatient hospital care. You say that it is felt that criteria are met for
payment of this inpatient hospital claim. The Plan denied your request. The Plan says that a decision was not
made on this appeal within the required time frame. As such, it was sent to us for review.
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 pay for the acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee presented to the emergency department on November 3, 2020 with
diarrhea. She had recently tested positive for COVID-19, and her chest x-ray showed pneumonia. She was
admitted for evaluation of her COVID diagnosis and electrolyte imbalance. The review has determined that the
record did not show that at the time of inpatient admission the admitting physician reasonably expected that the
patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided on November 3, 2020.
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.