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 the enrollee requires physical therapy and acute care 
due to their injury. The Plan denied your request. The Plan says an IRF admission 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 18, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with 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 a $200 
copayment for outpatient surgery/ambulatory surgical center. 
 
You have been asked to pay a $200 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/ambulatory surgical center 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 an outpatient surgery provided on September 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested drug is subject to step therapy criteria. 
The enrollee has not tried and failed the preferred step therapy drugs Infed (iron dextran- Allergan has INFeD 
50 mg/mL 2 mL vials available) and Venofer (iron sucrose). There is no indication the preferred drugs would 
likely be: less effective, and/or cause adverse effects for the enrollee.  
 
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 Feraheme. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that based on the medical records 
provided, there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on December 19, 2022,
billed under code 22830.

You asked the Plan to pay for this claim as billed. You say that the Plan denied your request. The Plan says the
Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information
regarding the denial. The Plan requested a reopen and submitted additional information. The Plan demonstrates
that Procedure code 22830-AS-51, an exploration of spinal fusion is documented in the operative note
submitted for review; however, this procedure is considered inclusive to CPT code 22551-AS, an arthrodesis
using an anterior interbody approach, including disc space preparation, discectomy, osteophytectomy and
decompression of spinal cord and/or nerve roots, for a single cervical interspace below C2. The documents
received do not support that the procedure or service was distinct or independent from other services
performed; therefore, the use of the 59 modifier is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and when necessary, the appropriate modifier. The
records provided do not support the modifier billed. Therefore, we decided that the Plan does not have to pay
for services provided to the enrollee on December 19, 2022, billed under code 22830.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (inclisiran). 
 You asked the Plan to pre-approve Leqvio. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Leqvio. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has hypercholesterolemia and Atherosclerosis heart disease. The documentation does not 
support that the enrollee has tried and failed Repatha. The documentation does not support that Repatha would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio (inclisiran).
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 had back surgery and contracted COVID-19 and 
unable to go home because of health issues with your husband. You stay in bed until your physical therapy, and 
want to go to inpatient rehabilitation for continued therapy to get better to return home. The Plan denied your 
request. The Plan says your condition does not meet all the requirements for inpatient rehabilitation admission. 
The Plan says services may be provided at a lower level of care.  
 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the dual-energy X-ray absorptiometry (DXA) (77085) provided on June 
28, 2023. 
 
You asked the Plan to pay for the DXA. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says that the claim did not include a diagnosis code from the benefits 
screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, 
hyperparathyroidism, or steroid therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the rule used by the Plan to outright deny code 77085 for billing 
issues does not apply to code 77085. The Local Coverage Article (A59040) for this service with jurisdiction 
over the state where this service was performed does not indicate that there are certain diagnosis codes which 
automatically are considered not medically necessary when paired with the service at issue. The Plan has not 
fully substantiated their denial in this case. Therefore, we decided that the Plan has to pay for the dual-energy 
X-ray absorptiometry (DXA) (77085) provided on June 28, 2023.  
 
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 waive the copayment for inpatient hospital care provided on April 
19, 2023, to April 25, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with 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 a $325 
copayment for inpatient hospital care. 
 
You have been asked to pay a $325 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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. The total amount you owe is $1,625 ($325 x 5 days = $1,625). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on April 19, 2023, to April 
25, 2023.
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 meets full criteria for admission to the 
IRF and you would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says admission to the IRF 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. 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 medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrolee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 06, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for laboratory services provided on June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatry services provided on August 07, 2023. 
 
You asked the Plan to pay for the psychiatry services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the psychiatry services provided on August 07, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional direct skilled nursing services of a 
registered nurse in the home health or hospice setting each 15 minutes (G0299). 
 
You asked the Plan to pre-approve additional home health 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. 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 additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
clinical documentation does not specify any acute clinical status, medication or plan of care change or complex 
wound care required. The records do not show that additional home health skilled nursing services (G0299) are 
required to effectively provide treatment, care, and/or services in order to improve your condition, or to 
establish/perform a maintenance program to maintain your condition 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 additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional direct skilled nursing services of a registered nurse in the 
home health or hospice setting each 15 minutes (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for June 14, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for June 
14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
September 29, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 pay for the urine polymerase chain reaction (PCR) 
panel rendered on September 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 06, 2023. 
 
You asked the Plan to pay for the home visit. You say that you do not agree with the denial of payment. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the home visit provided on January 06, 2023.
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 this device is medically necessary. The Plan
denied your request. The Plan says the Medicare coverage criteria are not met. Maximus partially 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 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. Claims for ventilators used to provide CPAP or bi-level
CPAP therapy will be denied as not reasonable and necessary. Approval for three months for transition has not
been demonstrated to be necessary based how the device is being used. The medical records show the enrollee
has severe COPD and has been using a home ventilator since 2017. Recent compliance indicates 100% use for
at least 4 hours daily. However, there is no diagnosis of thoracic restrictive disease or neuromuscular
disease. The enrollees respiratory support needs could be met with BiPAP with AVAPS and a backup
rate. Medicare does not cover a home ventilator when used at settings that can be provided with
BiPAP. Alarms and a backup battery are 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 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.