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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria.  
 
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 
was admitted for peripheral vascular surgery of the lower extremity. 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 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and garments 
(E0667). 
 
You asked the Plan to pre-approve pneumatic compression device and garments. You say that due to the 
circumstances of your legs, you need the pump in order to no be dead in 6 months. The Plan denied your 
request. The Plan says the records do not show the enrollee meets the criteria  
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
garments. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee with lymphedema related to venous 
insufficiency who reported significant benefit with physical therapy and compression wrapping. A request was 
made for a pneumatic compression device E0651 and garments E0667. The provided documentation does not 
support failure of conservative treatment, nor was there evidence of an ulcer or other indication required to 
meet criteria for the pneumatic compression device 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 pneumatic compression device and garments have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and garments 
(E0667).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade (J1745). 
 You asked the Plan to pre-approve Remicade. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred drugs, Enbrel, 
Humira, Otezla, Rinvoq, Skyrizi, Stelara, Xeljanz, or Xeljanz XR. 
 
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 Remicade. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer also found that there is no 
documentation provided indicating that the Plans required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have 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 Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade (J1745).
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 currently meets full IRF criteria. The 
Plan denied your request. The Plan says the enrollee does not require 24 hour nursing and the notes do not 
show if the enrollee will be able to participate in three hours 
a day of therapy.  
 
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 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 the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on July 01, 2023, to September 18, 
2023. 
 
You asked the Plan to pay for a facility visit. You say that the enrollee is in a facility and the facility should 
have obtained the prior authorization. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 a facility visit provided 
on July 01, 2023, to September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the routine physical and the office visit
provided on November 16, 2022.

You asked the Plan to waive the cost-sharing for the routine physical and the office visit. You say that you do
not agree with the cost sharing applied to these services. The Plan denied your request. The Plan says this cost
sharing was charged correctly. Maximus overturned the Plan's denial for a lack of information. The Plan
requested a reopening and stated that you were 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 $20
copayment for an annual routine physical exam and a 20% coinsurance for facility evaluation and management
services.

You have been asked to pay a $20 copayment for the routine physical and a 20% coinsurance for the office
visit. The routine physical falls within the annual routine physical exam benefit category and the office visit
falls within the facility evaluation and management services 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 cost-sharing for the routine physical and the office visit provided on November 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on September 
06, 2023. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you do not think that you 
should be charged. 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 $40 
copayment for each Medicare-covered x-ray. 
 
You have been asked to pay a $40 copayment for a breast ultrasound. This item/service falls within the each 
Medicare-covered x-ray 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 a breast 
ultrasound provided on September 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Supartz. 
 You asked the Plan to pre-approve Supartz. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says a repeat injection is not supported. 
 
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 Supartz. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Supartz. Our physician reviewer found the 
enrollee does meet criteria for viscosupplementation of the knee. However, the enrollee has not tried and failed 
the Plan's preferred products of Orthovisc and Synvisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Supartz.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too acute for a skilled 
nursing facility to manage. The appellant says that the LTACH level of care is the only option for a safe 
discharge due to the need for hourly respiratory and nursing care, daily physician management, frequent 
pulmonary toileting, telemetry, continuous pulse oximetry monitoring, oxygen weaning, intravenous 
medications, frequent labs, and physical, occupational, and speech therapies. The Plan denied your request. The 
Plan says  the LTACH services are not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has diabetes, diabetes, obstructive sleep apnea, and chronic obstructive 
pulmonary disease on home oxygen was admitted to the hospital with acute respiratory failure from 
Respiratory syncytia Virus (RSV). The enrollee required intubation and was diagnosed with cardiomyopathy. 
The enrollee is not on the ventilator and does not have complex wound care needs. The enrollee can continue 
care in the current setting until the enrollee is ready for a lower level of care as no therapeutic benefit is 
anticipated from a LTACH transfer. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) 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 before admission the enrollee was independent, at 
present time cannot even get out of bed and is not safe to return home. The Plan denied your request. The Plan 
says the enrollee's 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 the enrollee's 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 the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement advanced knee for a lower-limb 
prosthesis. 
 
You asked the Plan to pre-approve an advanced knee. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payments for repair and maintenance may not 
include payment for parts and labor covered under a manufacturers or suppliers warranty. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an advanced knee have not been met. Specifically, the case record indicates that the enrollee's existing advanced knee is under warranty at this time. Therefore, we decided that the Plan does not have to pre-
approve a replacement advanced knee for a lower-limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning services described by code 99497 
billed for date of service August 4, 2023. 
 
You asked the Plan to pay for 99497. You say that 99497 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99497 is denied because it is not supported in the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate.  
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 99497. Our reviewer says that 99497 is not 
supported in the documentation. Our reviewer found the enrollee is a 60-year-old with a history of gout who 
was admitted to the hospital for joint pain and swelling for 2 weeks and was diagnosed with acute gout flare. 
They were treated with steroids, colchicine, and fluids. The documentation does not reflect a separate 
discussion with the enrollee specifically to discuss advanced care directives. Therefore, without sufficient 
support, the billing of 99497 is not appropriate. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99497 have not been met. Therefore, we decided that the Plan does not have to 
pay for the advance care planning services described by code 99497 billed for date of service August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have  to waive the coinsurance for the Medicare Part B drugs and the 
copayment for the specialist office visits obtained by an out-of-network provider on September 5, 2023. 
 
You asked the Plan  to waive the coinsurance for the Medicare Part B drugs and the copayment for the 
specialist office visits. You say that the cost share is wrong. 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 30% 
coinsurance for Medicare Pat B drugs and a $75 copayment for specialist visits obtained out-of-network.  
 
You have been asked to pay a 30% coinsurance for Medicare Pat B drugs and a $75 copayment for specialist visits that were obtained out-of-network. 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 coinsurance for the 
Medicare Part B drugs and the copayment for the specialist office visits obtained by an out-of-network provider 
on September 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM).

You asked the Plan to provide coverage for a continuous glucose monitor (CGM). You say that at the 
time of the appeal, a continuous glucose monitor (CGM) was medically necessary. The Plan denied 
your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the 
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at
least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood
glucose testing results and have had an in-person visit with their treating physician to assess adherence to their
CGM regimen and diabetes treatment plan. All these criteria must be met for coverage to be approved. Based
on the medical records provided, you did not meet all the criteria listed at the time of the appeal. Therefore, we
decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM).