Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided to the enrollee
from November 23, 2022, to December 22, 2022.

You asked the Plan to pay for SNF care. You say that these services were medically necessary. The Plan denied
your request. The Plan says the Medicare coverage criteria were not met and these services were denied upon
admission. Maximus overturned the Plans denial due to a lack of medical records in the case file. The Plan
requested a reopen and submitted the required medical records.

The medical records show the enrollee was a long-term care (LTC) resident at a SNF. The enrollee was
admitted to an acute care hospital on November 18, 2022, for combative behavior and non-compliance with
chronic medications. Upon completion of her care in the acute setting, a request was made to the enrollee's
Medicare Plan to transfer her back to the facility as a LTC resident. This was denied as a Medicare noncovered
service. The enrollee transferred back to the facility under her state Medicaid benefit. Upon arrival to
the facility, she underwent a physical therapy (PT) evaluation, and it was determined that skilled therapy was
not needed. She also underwent an Occupational Therapy (OT) evaluation and was recommended for OT three
times per week. During the dates of service in question, the enrollee received OT two times per week for two
weeks, three times per week on one week and four times per week on one week. This does not satisfy the
Medicare requirement for daily or near daily therapy for a stay to be considered skilled. The enrollee was
functioning at or near her physical baseline and received OT for self-care management training that was not
provided on a daily or near-daily basis.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
Based on the medical records provided, the enrollees needs were custodial in nature which is not covered by
Medicare. The enrollee was reverted to the original Medicaid coverage for LTC residency. Therefore, we
decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided to the enrollee from
November 23, 2022, to December 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service June 18, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the code billed. The Plan 
denied your request. The Plan says code 99285 is not supported by the medical record. The medical records 
don't support a high level of medical decision making. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 We asked our coder 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical records. Our reviewer found the enrollee is an 83-year-old female who presented with 
rash as well as chest pain and shortness of breath. She was treated for allergic reaction and received treatment 
in emergency room.  Although history and exam was comprehensive and appropriate, the problem is acute and 
uncomplicated. Therefore, the documentation does not support a high level of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service June 18, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the walker (E0143) provided on May 24, 2023. 
 
You asked the Plan to pay for the walker. The Plan denied your request. The Plan says that code E0143 was not 
billed with the KX modifier. 
 
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. The Plan argues that code E0143 was not billed with the KX modifier. However, 
per LCA A52503, code E0143 does not require the use of the KX modifier. Per A52503, the KX modifier is 
only required for codes E0148 and E0149. The Plan has not provided documentation supporting its denial. As 
such, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the walker 
(E0143) provided on May 24, 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission would minimize 
the enrollee's risk of returning to a short-term acute care hospital. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH. 
 
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 is presently receiving appropriate services in the current acute care 
setting. Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a 
lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled 
nursing facility. The health plan has stated that continued care in the short-term acute hospital will be covered 
as is medically indicated. 
 
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: 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 item is medically necessary. The Plan 
denied your request. The Plan says the item 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 item is not medically necessary. Our physician reviewer found the ventilator will be used as 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on August 7, 
2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that it was an internal 
mistake on the hospital's end and you don't think you should have to pay the $95 copay. 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 $95 
copayment for emergency care.  
 
 
 You have been asked to pay a $95 copayment for an emergency room visit. This item/service falls within the 
Emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
visit on August 7, 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 needs the therapy offered by the 
rehabilitation facility to regain their prior level of functioning. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for services in an IRF.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. Although the enrollee could tolerate the therapy in the IRF, the complexity of 
their condition doesnt require an IRF stay and care can be provided in a lower level.  
 
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 genicular artery embolization.  
 
You asked the Plan to pre-approve genicular artery embolization. You say that genicular artery embolization is 
medically necessary. The Plan denied your request. The Plan says genicular artery embolization is 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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary. Our physician reviewer found that genicular artery embolization is an experimental/investigational 
procedure and is the subject of ongoing clinical trials. Therefore, the request is deemed not medically 
reasonable and 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Renflexis. 
 You asked the Plan to pre-approve Renflexis. You say that the enrollee cannot afford cost-sharing and 
Renflexis offers a patient assistance program which neither Inflectra nor Avsola offer. The Plan denied your 
request. The Plan says the Plan requires a trial of Inflectra or Avasola before it will approve Renflexis. 
 
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 Renflexis. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Renflexis. Our physician reviewer found the 
enrollee has not tried and failed Inflectra or Avsola. The record does not show that these drugs would likely be 
less effective and/or 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 Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Renflexis.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
18, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are providing a waiver of liability form along 
with medical records. The Plan denied your request. The Plan says Medicare payment cannot be made to this 
type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on August 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 

You asked the Plan to pre-approve Xgeva. You 
say that the requested drug is medically necessary. The Plan denied your request. The Plan says Xgeva is subject to step therapy criteria. The enrollee has not tried and failed the preferred step therapy drug(s): 
intravenous pamidronate or zoledronic acid.  
 
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 Xgeva. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that based on the medical records 
provided and the Medicare-approved major drug compendia, zoledronic acid should be avoided due to the 
enrollee's renal failure. As summarized in Micromedex: "The use of zoledronic acid in patients with bone 
metastases and severe renal impairment is not recommended; patients with a SCr [serum creatinine] greater 
than 3 mg/dL were excluded from clinical trials [22]." There is no indication that pamidronate would likely be 
less effective and/or likely have adverse effects for the enrollee although very close monitoring of the 
enrollee's renal function would be required.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you need knee surgery, and you 
have limited mobility. The Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power operated vehicle. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you have chronic back and knee 
pain. You have limited ambulation but are able to complete activities of daily living. Per NCD 280.3, you do 
not require a powered device to complete self-care in the home.  
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 1 standard power operated vehicle, patient weight capacity up to and 
including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of skin substitute Axolotl and Axolotl 
Dualgraft. 
 You asked the Plan to pre-approve application of skin substitute Axolotl Graft and Axolotl Dualgraft. You say 
that the requested service is medically necessary to treat the enrollee. The Plan denied your request. The Plan 
says the requested procedure is 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 application of skin substitute Axolotl 
Graft and Axolotl Dualgraft. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee's left leg ulceration is 
improving with standard wound debridement and dressings. There is no mention of a wound vacuum assisted 
closure (VAC) that has been tried and failed, which is also standard of care for large wounds. The 
documentation is unclear as to why application of skin substitute Axolotl and Axolotl Dualgraft is medically 
necessary when the ulcer is healing with wound debridement and dressings. Furthermore, the enrollee does not 
meet the LCD criteria coverage for application of skin substitute. The medical documentation supports that this 
wound is healing/closing/reducing in size with standard wound debridement and dressings. LCD criteria for 
application of skin substitutes requires a nonhealing ulceration. Therefore, the enrollees left leg ulceration 
does not meet the LCD criteria for coverage of skin substitutes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of application of skin substitute Axolotl Graft and Axolotl Dualgraft have not been 
met. Therefore, we decided that the Plan does not have to pre-approve application of skin substitute Axolotl 
and Axolotl Dualgraft.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
16, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are sending a waiver of liability form with 
medical records to appeal the denial decision. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 16, 2023.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Ilumya. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed corticosteroids 
and oral therapy was discussed but is too costly for the enrollee. The Plan denied your request. The Plan says 
that that step therapy requirements have 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 the medication. Our reviewer says that 
the criteria for coverage of Ilumya have been met. Our physician reviewer found that the Plan requires a trial of 
Avsola, Inflectra, and Renflexis before they will approve the requested drug. In this case, the plans required 
drugs are likely be less effective and/or likely have adverse effects for the enrollee. The requested medication is 
the community standard 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 the medication have been met. Therefore, we decided that the Plan has to pre-
approve Ilumya.  
 
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.