Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the cervical and lumbar spine for the enrollee.
You asked the Plan to pre-approve an MRI of the cervical and lumbar spine. You say that this imaging is medically necessary for the enrollee. The Plan denied your request. The Plan says that Medicare coverage criteria are not met. Maximus partially overturned the Plans denial. The Plan requested a reopen for clarification of the services reviewed.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered when they are medically 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 this imaging. Our physician reviewer found the request for MRI of the cervical and lumbar spine in this enrollee with bilateral lower extremity weakness and numbness should be approved. This is a red flag due to the weakness in the absence of pain. Such symptoms may be related to cord compression. Therefore, MRI of the cervical and lumbar spine should be approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the cervical and lumbar spine are met. Therefore, we decided that the Plan has to pre-approve MRI of the cervical and lumbar spine for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says that these services are not medically necessary based on IRF criteria for coverage. 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 IRF care.
Our Medical Director states that clinical documentation does not sufficiently support that the complexity of the enrollee's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, that the enrollee required treatment by multiple therapies, including either physical therapy or occupational therapy and an intensive rehabilitation therapy program, and that there was a reasonable expectation that this enrollee would be able to fully participate in, and benefit from, the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that the services you need can be provided safely in other settings.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not support that the complexity of your nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Rather, it appears that the required therapy services could have been provided in another setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Partially Favorable

 
We decided that the Plan has to pre-approve MRI of the spine. We decided that the Plan does not have to pre-
approve MRI of the pelvis.  
 
You asked the Plan to pre-approve magnetic resonance imaging (MRIs) of the spine and pelvis.. You say that 
these scans are medically necessary. The Plan says that imaging requires 6 weeks of provider-directed 
treatment to be completed before it can be approved.  We decided that the Plan has to pre-approve MRI of the spine.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRIs. Our reviewer says that the 
enrollee meets criteria for the requested MRI of the spine. Our physician reviewer found the enrollee has 
bilateral leg weakness and numbness. The request for cervical/lumbar spine MRI in this enrollee with bilateral 
lower extremity weakness and numbness should be approved as a red flag due to the weakness in the absence 
of pain. Such symptoms may be related to cord compression.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRIs have been met. Therefore, we decided that the Plan has to pre-approve 
MRI of the spine.  
 
We also decided that the Plan does not have to pre-approve MRI of the pelvis. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI of the pelvis. Our reviewer says 
that the enrollee does not meet criteria for MRI of the pelvis. Our physician reviewer found that during the 
examination on April 3, 2023 there was no discussion or plan concerning MRI of the pelvis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the pelvis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MRI of the pelvis. 
 
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: 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 require IRF care. The Plan denied your request. The Plan says that based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care.
Our Medical Director states that the clinical documentation does not support that the complexity of the patient's nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our Medical Director found that your condition does not meet Medicare criteria for IRF 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: 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 disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary. 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 IRF care.
Our Medical Director states that there is insufficient clinical documentation to support that the complexity of your nursing, medical and rehabilitation needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, there was not a reasonable expectation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our Medical Director found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.

You asked the Plan to pre-approve a sacroiliac joint injection. You say that a sacroiliac joint injection is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac joint injection does not meet the Medicare coverage criteria.

The Plan follows Medicare rules.

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 sacroiliac joint injection. Our reviewer says that the requested sacroiliac joint injection is not considered medically necessary. Our physician reviewer found that sacroiliac joint (SIJ) injections are recommended as an option if the patient has failed at least 4-6 weeks of aggressive conservative therapy including, physical therapy (PT), home exercise and
medication management. There should be evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. At least three (3) positive exam findings of SI joint dysfunction should be present on physical exam such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. In this case, there is no documentation on physical examination of three (3) or more positive tests results. The clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed literature. The review has determined that the requested sacroiliac joint injection does not meet the Medicare LCD coverage criteria.

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 sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs a ventilator to reduce hospital admissions. The Plan denied your request. The Plan says that a BiPAP will meet the enrollee's needs.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a home ventilator. Our Medical Director states that the case file does not contain documentation of trial and failure of BiPAP with backup rate and average volume-assured pressure support (AVAPS). The documentation is insufficient to support that a home ventilator (E0466) is medically reasonable and necessary in this case. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for a home ventilator.
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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs 15 liters of oxygen, and a lower level of care facility is not going to be able to supervise carefully. The Plan denied your request. The Plan says that the coverage criteria has not been 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 IRF care. Our Medical Director states that the clinical documentation did not support that there was a reasonable expectation that this enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Leqvio for the enrollee.
You asked the Plan to provide coverage for Leqvio. You say that the enrollee cannot afford Repatha and cannot administer Repatha. The Plan denied your request. The Plan says cost is not a valid reason to make an exception for step therapy rules and the medical records do not support that the enrollee is unable to administer Repatha. Maximus overturned the Plans denial for medical necessity, stating Leqvio is an acceptable drug for the enrollee's condition. The Plan requested a reopen and stated that Maximus did not apply the required step therapy criteria.
The Plan is correct in this case. 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. The medical records provided do not sufficiently show the enrollee is unable to medically use or administer Repatha. Cost concerns are not a reason to make exceptions for the Plans required step therapy requirements Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to provide coverage for Leqvio for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene analysis provided to the enrollee on July 7, 2021, and billed under codes 81286, 81400, 81413, 81414, 81442 and 81479.
You asked the Plan to pay for gene analysis. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus partially overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required medical records. The Plan noted that several requests were made for verification of who wrote the order for this testing. The notes state the following "His family asked if the patient needed any kind of genetic testing. I reviewed his records extensively and he does not have any diagnosis of hypertrophic cardiomyopathy or any other inherited cardiogenetic disorder that would warrant genetic testing".
The Plan is correct in this case. 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 is not supported in the medical records as being needed to direct treatment or disease present in the enrollee at the time of the appeal. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for gene analysis provided to the enrollee on July 7, 2021, and billed under codes 81286, 81400, 81413, 81414, 81442 and 81479.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
April 5, 2022, to April 9, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this 
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 a $320 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you must pay a $0 copayment per day for any additional days. You have been asked to pay a $320 copayment per day for days 1-4 of the inpatient hospital stay. You have not 
been charged for the day you were discharged. These items/services fall within the inpatient hospital care 
benefit category. You have been asked to pay a total of $1,280 ($320 copayment per day x 4 days = $1,280). 
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 the inpatient hospital stay provided from April 5, 2022, to 
April 9, 2022.
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 requires a higher level of care than the 
home setting or a skilled nursing facility can provide. The Plan denied your request. The Plan says the enrollee 
does not meet all the required Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) 
provider on December 13, 2022, to December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) provider on December 13, 2022, to December 
22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bronchoscopy (31647, 31651). 
 
You asked the Plan to pre-approve the bronchoscopy. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bronchoscopy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records did not show report of a blood gas test or persistent symptoms despite pulmonary 
rehabilitation. There is no indication that the enrollee had pulmonary rehab and still continues to have 
symptoms. There is also no six-minute walking test provided. Because the procedure requested is not medically 
necessary, the related inpatient hospital admission is also not 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 the bronchoscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the bronchoscopy (31647, 31651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that you were approved for the electric mechanism 
only. You also say that the whole thing should be covered. The Plan denied your request. The Plan says a 
recliner chair is not a covered benefit as there is no medical purpose. 
 
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 recliner chair.