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 the enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollees medical condition does not require LTACH services, 
and care can be provided 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 enrollee is receiving appropriate care in their current acute care setting. The 
documentation does not support that LTACH services are medically appropriate 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve triptorelin. 
 You asked the Plan to pre-approve the drug. You say that you were prescribed some medications which was 
denied. The Plan denied your request. The Plan says that the 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 drug. Our reviewer says that 
triptorelin is not medically necessary. Our physician reviewer found that you have not tried and failed the 
Plan's required drugs Eligard and Lupron. Also, there is no indication that the Plan's required drugs would 
likely be less effective or would likely have adverse effects for you. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve triptorelin.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 14, 2022. 
 
You asked the Plan to pay for ambulance services. You say that you have reported the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 14, 2022. Coverage for ambulance 
services without transport is available for providers who have elected to participate in a pilot program. The 
program is limited to Medicare FFS enrollees. In this case, the enrollee is a Medicare Advantage enrollee. The 
ambulance benefit is a transportation benefit. When there is no transport of a Medicare Advantage enrollee, 
neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have 
to pay for ambulance services provided on December 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to an 
appointment. The Plan denied your request. The Plan says the requested trip exceeds your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full arm (E0668), segmental pneumatic appliance for use with 
pneumatic compressor, chest (E0657), and segmental pneumatic appliance for use with pneumatic compressor, 
trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compressor, full arm segmental pneumatic appliance, chest 
segmental pneumatic appliance, and segmental pneumatic appliance for the trunk. 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 pneumatic compression devices are covered when 
specific 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 a pneumatic compressor, full arm 
segmental pneumatic appliance, chest segmental pneumatic appliance, and segmental pneumatic appliance for 
the trunk. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee has failed at least 4 weeks of conservative care with a basic 
lymphedema pump.   
 
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 pneumatic compressor, full arm segmental pneumatic appliance, chest 
segmental pneumatic appliance, and segmental pneumatic appliance for the trunk have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668), segmental pneumatic appliance for 
use with pneumatic compressor, chest (E0657), and segmental pneumatic appliance for use with pneumatic 
compressor, trunk (E0656).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the injection services described by code 64415 performed on date of 
service May 25, 2023. 
 
You asked the Plan to pay for 64415. You say that 64415 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says that 64415 is denied because a review of the 
records indicates 64415 was performed preoperatively. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plans rationale in this case is that the records show 64415 was 
not used for postoperative pain management but was instead performed preoperatively. However, the records 
submitted in the case file to Maximus are substantially illegible to the extent that we cannot independently 
verify this rationale. Maximus requested legible records from the Plan but received no response as of the appeal 
due date. Therefore, we decided that the Plan has to pay for the injection services described by code 64415 
performed on date of service May 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage for a CGM requires 
insulin use or low blood sugars. This enrollee is not on medications for diabetes mellitus and not having low 
blood sugars that we are told of. If there is additional information, it should be submitted and the case re-
reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the request is not reasonable and necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do 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. There is a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but the services required can be provided at 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: 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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at their maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission to 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. 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.  
 
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: 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 this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this is experimental and therefore is not 
covered. 
 
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 CardioMEMS device is 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. Therefore, the reviewer 
found that the requested CardioMEMS device is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a 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 a non-elastic binder for an extremity (A4465). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wound care items that do not meet the definition 
of a dressing are not covered. 
 
The requested wound care item does not meet the statutory definition of a wound care dressing. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a non-elastic binder for an extremity (A4465).
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 are requesting reconsideration of denied 
authorization The Plan denied your request. The Plan says based on Medicare guidelines, the Inpatient 
Rehabilitation Facility (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 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy in an 
intensive rehabilitation therapy program. Medically necessary care can be provided in a different level of care. 
There is no 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and 
placement of transfixing device (27279). 
 
You asked the Plan to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device. You say that this is medically necessary. The Plan denied your request. The Plan says this is 
not medically necessary because the records show the enrollee has significant magnetic resonance imaging 
findings that can be causing low back pain. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous minimally invasive fusion/stabilization 
of the sacroiliac joint (SIJ) for the treatment of back pain can be covered when specific criteria is 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 arthrodesis, sacroiliac joint, 
percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft 
when performed, and placement of transfixing device. Our reviewer says that the enrollee does not meet 
criteria for coverage. Our physician reviewer found the records show that the enrollee has significant magnetic 
resonance imaging findings that can be causing low back pain. There is a large, extruded disc and severe spinal 
stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, 
includes obtaining bone graft when performed, and placement of transfixing device (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with multiple 
power options (seat elevator, tilt/recline, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair with multiple power options. You 
say that the enrollee medically required powered seating functions on their unit to address specific needs 
outlined in the attached specialty mobility evaluation. The Plan denied your request. The Plan says the enrollee 
does not have a qualifying diagnosis causing mobility limitation for which a Group 3 power wheelchair is 
medically needed.  
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to a neurological condition, myopathy, or congenital 
skeletal deformity. 
 
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 heavy duty power wheelchair 
with multiple power options. Our reviewer says that the requested Group 3 heavy duty power wheelchair with 
multiple power options is not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee has a documented diagnosis that would meet criteria for a Group 3 power 
wheelchair. Therefore, the reviewer found that the requested Group 3 heavy duty power wheelchair with 
multiple power options is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 heavy duty 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 heavy duty power 
wheelchair with multiple power options (seat elevator, tilt/recline, legrests) and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve the medication. You say that you would like reconsideration based on the 
records submitted The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate 2.5 mg tablets. 
 
You asked the Plan to pre-approve methotrexate. You say that the enrollee has been taking this medication for 
many years and it is working well. This request is to continue with this course of treatment. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve methotrexate 2.5 mg tablets.  
 
Benefits for methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.