Persius/hicric huggingface dataset:
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 you need rehab therapy services that can 
be received in a LTACH setting. The Plan denied your request. The Plan says when you are ready to leave the 
hospital you can receive your care in another setting. 
 
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 record indicates that you are improving but still require acute care services before 
transitioning to a lower level of care. You continue to receive acute care services, and these have not been 
denied. The medical record does not indicate that you require services that you are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal tract imaging. 
 
You asked the Plan to pre-approve gastrointestinal tract imaging. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the requested service does 
not meet the requirements for approval. 
 
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 gastrointestinal tract imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that you have fecal occult blood positivity. The record 
indicates that you last underwent endoscopy over two years ago when you were treated for gastrointestinal 
bleeding. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastrointestinal tract imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve gastrointestinal tract imaging.
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 is medically 
necessary. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The requested service cannot be 
recommended as the elements of the coverage rules are not satisfied. 
 
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 pay for inpatient hospital services provided on January 13, 2023, to 
January 24, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G92.9, described as 
unspecified toxic encephalopathy. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the enrollee is a 67-year-old female with baseline advanced dementia 
and schizophrenia who was treated in the hospital with a urinary tract infection. It was reported that she was 
experiencing progressive decline in mental status prior to the hospitalization and was lethargic and confused on 
admission which did not change significantly during the entire hospital stay. Therefore, it appears that the 
enrollee was at her baseline mentally which does not support the diagnosis code, G92.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 13, 2023, to January 24, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system (L5981) for the enrollee.

You asked the Plan to pre-approve a flex-walk system. You say that this item is medically necessary. The Plan
denied your request. The Plan says that the records do not support the enrollee is a K3 ambulator.

The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plan's denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the enrollee's
physician states a K3 foot is medically necessary as the enrollee is a K3 ambulator. However, this is not
consistent with available medical history. Medicare covers items that meet, but do not exceed, the member's
need. The medical records do not show why the enrollee requires a K3 foot, or why a standard foot would not
meet the enrollee's needs. Therefore, the documentation does not demonstrate that the enrollee is a K3
ambulator.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say the documentation
provided does not support that the enrollee was a K3 ambulator at the time of the appeal. Medicare rules for
coverage of the requested prosthetic equipment have not been met. Therefore, we decided that the Plan does
not have to pre-approve a flex-walk system (L5981) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Dexamethasone Sodium Phosphate, 
Bevacizumab, Carboplatin, and Paclitaxel.  
 
You asked the Plan to pre-approve Keytruda, Dexamethasone Sodium Phosphate, Bevacizumab, Carboplatin, 
and Paclitaxel. You say that the provider states this is medically necessary. The Plan denied your request. The 
Plan says this drug regimen is not supported for the enrollee's condition.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda, Dexamethasone Sodium 
Phosphate, Bevacizumab, Carboplatin, and Paclitaxel. Our reviewer says that does not meet criteria.  Our physician reviewer found this combination is not FDA approved for the enrollees diagnosis. The 
requested combination is not supported by one of the major drug compendia or by clinical research appearing 
in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Dexamethasone Sodium Phosphate, Bevacizumab, Carboplatin, and 
Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, 
Dexamethasone Sodium Phosphate, Bevacizumab, Carboplatin, and Paclitaxel.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that without this procedure the enrollee is 
at risk for further hospitalization. The Plan denied your request. The Plan says the CardioMEMS system is not 
medically reasonable and 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the  
 CardioMEMS device would not be considered medically appropriate and necessary in the patients clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio test strips (A4253). 
 
You asked the Plan to pre-approve the OneTouch Verio test strips. You say that these test strips are medically 
necessary. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic testing supplies. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio 
test strips (A4253).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an OON provider.  
 
You asked the Plan to pre-approve OON SNF care. You say that the requested provider is close to the 
enrollee's family. The Plan denied your request. The Plan says in-network providers are available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
SNF care to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee is stable and ready to be 
discharged to a facility where she can continue with her progress. The Plan denied your request. The Plan says 
the enrollee does not meet the requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record indicates that the enrollee has ongoing acute medical issues 
and still requires acute care services. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of coverage rules are not satisfied. 
The requested services cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 4 home health skilled nursing visits 
(G0299 x4). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to be medically stable, and their oxygen saturation was 92-95% on room air. They do not require wound 
care, catheterization, tube feeding, or administration of intravenous or complex medications. The enrollee has 
been educated regarding their medications and they have not recently been hospitalized. They have had an 
exacerbation of their chronic obstructive lung disease requiring oral medications, but no onset of a new 
condition. The enrollee is receiving routine foot care that does not necessitate skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 4 home health skilled nursing visits (G0299 x4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spineology Optimesh expandible cage (22853). 
 
You asked the Plan to pre-approve Spineology Optimesh expandible cage. You say that this is medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the Spineology 
Optimesh expandible cage in the setting of severe lumbar stenosis have not been demonstrated in the peer-
reviewed literature. 
 
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 Spineology Optimesh expandible cage. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. Additionally, 
the approved spinal procedure did not clearly document the use of autograft or allograft for this procedure, and 
therefore does not meet the Food and Drug Administration indications for intended use. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spineology Optimesh expandible cage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Spineology Optimesh expandible cage (22853).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the nerve stimulator. You say that you are appealing the denial. The Plan 
denied your request. The Plan says the request 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 the nerve stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Sprint peripheral nerve stimulator is considered experimental/investigational 
and is not medically necessary for the treatment of chronic 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 the nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee prosthetic to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a below knee prosthetic. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the provider is out-of-network and prior authorization is required for an out-of-
network visit. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a below knee prosthetic to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the requested use of this drug combination is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our reviewer says that 
the requested use of pembrolizumab is FDA approved for the enrollees diagnosis. Our physician reviewer 
found that the use of pembrolizumab is also 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 the medication have been met. Therefore, we decided that the Plan has to pre-
approve pembrolizumab.  
 
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.