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

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee requires volume 
ventilation to maintain their respiratory status. You say that the enrollee requires ambulation ventilation to 
allow for mobility in the daytime. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).  
 
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. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has severe COPD with no documented arterial blood gas tests or failure of a BiPAP with or without AVAPS. 
Also there is no documentation to support a home ventilator. Therefore, a trial of a BiPAP with AVAPS would 
be the best practice. 
 
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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
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's condition requires a IRF level of care. 
The Plan denied your request. The Plan says the IRF services requested do not meet the requirements for 
approval.  
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee has limited range of motion and 
numbness in their hand. You say that this drug is necessary due to the failure of conservative treatments. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Orthovisc. Our reviewer says that 
Orthovisc is not medically necessary. Our physician reviewer found Orthovisc is considered experimental for 
shoulder pain. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that this is best most of treatment for the enrollee. The Plan 
denied your request. The Plan says this is not supported for the enrollee's condition. 
 
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 SBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this treatment remains investigational and is not in accordance with accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ruxience. 
 
You asked the Plan to pre-approve Ruxience. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says Ruxience is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ruxience. Our reviewer says that the 
requested use of Ruxience is not FDA-approved for the enrollees diagnosis. Our physician reviewer found the 
use of Ruxience is not supported by one of the major drug compendia or by clinical research. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ruxience have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ruxience.
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 an IRF admission to regain your full 
level of function. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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 can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in 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 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 pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that no one can find out why you are losing weight and 
you need a CT scan to find the cause. The Plan denied your request. The Plan says that the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the 
requested CT scan meets the criteria for coverage. Our physician reviewer found it is reasonable and necessary 
to do a CT scan of the abdomen and pelvis to assess weight loss 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan.  
 
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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. 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. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from August 23, 2021, to August 31, 
2021. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the claim was not 
filed in a timely manner. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 The record shows that a corrected claim for SNF services was not filed until May 20, 2023. This means that 
more than one calendar year from the date of service had passed before a corrected claim was filed. Therefore, 
we decided that the Plan does not have to pay for SNF services provided from August 23, 2021, to August 31, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for heparin injections provided from January 24, 2023, to 
January 27, 2023. 
 You asked the Plan to pay for the medication. You say that the services are covered under Medicare guidelines. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for heparin injections provided from January 24, 2023, to 
January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs a ventilator. The Plan 
denied your request. The Plan says this is not medically necessary. 
 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. 
 
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 home ventilator. Our reviewer says 
that the requested ventilator is not medically necessary. Our physician reviewer found the enrollee tolerated 
and improved with average volume-assured pressure support (AVAPS) that was delivered with bi-level 
positive airway pressure (BiPAP). 
 
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 (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (E0955, E0956, E0957, E1007, E1012, E1028, E2300, E2311, E2313, E2363, E2377, E2609, E2617, 
K0108, K0861).  

You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 power wheelchair with 
multiple power options. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (E0955, E0956, E0957, E1007, E1012, E1028, E2300, E2311, E2313, E2363, E2377, E2609, 
E2617, K0108, K0861).
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 an IRF admission is medically necessary. The Plan
denied your request. The Plan says that the IRF services you or your provider are requesting do not meet the
requirements for approval. Maximus overturned the Plan's denial stating IRF care would be beneficial. 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 IRF admission is
covered only when it is medically reasonable and necessary as described in the Medicare rules section. The
rules are clear that you must meet specific criteria prior to admission for IRF care to be covered. Whether or
not the care would be beneficial is not an appropriate review, the records clearly show that at the time of the
appeal prior to admission the enrollee did not meet all the criteria required by Medicare for coverage.
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-spinal electrical spinal bone growth stimulator 
(E0747). 
 
You asked the Plan to pre-approve non-spinal electrical spinal bone growth stimulator. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator 
(E0747) is covered only if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve non-spinal electrical spinal bone growth 
stimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found not 
enough time has passed since the enrollee's foot surgery to establish diagnosis of nonunion. More time is 
needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-spinal electrical spinal bone growth stimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve non-spinal electrical spinal bone growth 
stimulator (E0747).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing services performed from February 5, 2023, to February 
28, 2023. 
 
You asked the Plan to pay for the SNF services. You say that the records provided support payment for the 
services in dispute. The Plan denied your request. The Plan says that the enrollee was ambulating with staff in 
the room and hallway at times. 
 
The Plan follows Medicare rules. Medicare rules say that codes can be billed for single room isolation when 
certain conditions are met. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the documentation does support that the 
enrollee had an infectious disease, was on isolation precautions and received care in his room. While the daily 
notes do note ambulation, these notes appear to be copy/cut/pasted. Our physician reviewer found that the 
statements regarding ambulation are from prior and reference the enrollees general baseline, not what was 
occurring in early February 2023. 
 
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 SNF services have been met. Therefore, we decided that the Plan has to pay 
for skilled nursing services performed from February 5, 2023, to February 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 return payment for the inpatient hospital items/services provided 
from January 17, 2023, through February 8, 2023, recouped under denial codes G and H.  
 
You asked the Plan to return payment for the denied items/services. You say that it is felt that the removed 
charges were supported, and the original claim payment was correct. The Plan denied your request. The Plan 
says on appeal review, certain charges were found to be supported and were added back to the total claim cost. 
However, it was found that the services denied under code G and H were correctly removed.  
 
The Plan must follow Medicare rules. The rules state that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge.  
 
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 return payment for the denied items/services. Our 
reviewer says that the items/services removed from the claim are not supported for payment by the records.  
Our physician reviewer found under denial code G, the Plan has removed charges totaling $23,748.76. Itemized 
bill for denied charges describe: nursing and ancillary services, as well as medical supplies for procedures 
performed. These services denied correctly as these services are considered "room and board" charges and 
would not be billed separately. Medical record does not support billing items separately. Under denial code H, 
$528 of charges were removed. Denied charge for 1/18/2023 is for Ventilator-adult initial was reimbursed. A 
second charge for service resulted in duplicate billing. In this case, denial for additional $528.00 denied 
correctly.   
 
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 denied items/services have not been met. Therefore, we decided that the 
Plan does not have to return payment for the inpatient hospital items/services provided from January 17, 2023, 
through February 8, 2023, recouped under denial codes G and H.