Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of OrthoVisc is required before alternatives can be considered. 
 
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 looked at the file, and Medicare rules. No clinical records were provided to show if there was a trial of the 
plans preferred drug. Based on this information, we decided that Medicare rules for coverage of Euflexxa have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on August 29, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on August 29, 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 IRF services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting 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 you are medically stable and do not need a physical medicine and rehabilitation 
physicians supervision 3 times a week in an IRF. There is no medical complexity. At the current functional 
level, you need physical therapy and occupational therapy. Our reviewer found that you do not need intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. The document does not support necessity for admission to an IRF. The complexity of your 
medical, rehabilitation, and nursing needs (combined complexity) does not require acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our physician reviewer also found 
that your rehabilitation can be safely provided in a low intensity alternate setting such as continuing in a skilled 
nursing facility.  
 
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 reduce the copayment for laminectomy, physical therapy (97161, 
97165) and self-administered drugs provided on July 31, 2023, to August 2, 2023. 
 
You asked the Plan to reduce the copayment for laminectomy, physical therapy (97161, 97165) and self-
administered drugs. You say that you were told your copayment should be $285. 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 $20 per 
day for Medicare-covered physical therapy services and $285 per day, per provider, for Medicare-covered 
outpatient hospital facility visit. 
 
You have been asked to pay a total of $325 for the laminectomy and physical therapy (97161, 97165). These 
item/service falls within the outpatient rehabilitation and outpatient surgery benefit category. You had a 
copayment of $40 for the physical therapy visits ($20 copayment x 2 visits = $40) and $285 copayment for the 
laminectomy. 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 reduce the copayment for the laminectomy and physical therapy 
(97161, 97165) provided on July 31, 2023, to August 2, 2023. 
 
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 reduce the copayment for the self-
administered drugs provided on July 31, 2023, to August 2, 2023. 
 
Benefits for self-administered drugs 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you received a Notice of Medicare Non-Coverage to 
end skilled services with the last covered day of January 11, 2024. The Plan denied your request. The Plan says 
your request for approval of continued admission in a SNF does not meet the requirements for approval. 
 
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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for transfer to the 
LTACH level of care, and if they are forced to be discharged to a lower level of care, they will be placed at an 
extremely high re-admission risk back to the acute hospital. You also say the enrollee clearly meets LTACH 
criteria, and would have already admitted if they had a straight Medicare policy. The Plan denied your request. 
The Plan says this request does 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 enrollee was admitted to the hospital with a hemorrhagic stroke. The enrollee has 
had a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placed. Our reviewer found that the 
enrollee has a persistent leukocytosis, low-grade fever, and erythema around their tracheostomy site. Our 
physician reviewer also found that the enrollee is not stable for transfer, and acute hospitalization in the current 
setting is still justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is needed for daily 
medical doctor visits including a pulmonologist, attending, and an infectious disease specialist. You also say 
that 24/7 registered nurse care is needed for complicated and extensive intensive care unit course and for 
complex medical needs including scheduled intravenous medications, daily labs, and close vitals monitoring.  
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for 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 was admitted with acute hypoxic respiratory failure secondary to 
influenza. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care 
services. The medical record does not indicate that the enrollee requires services not currently receiving but 
that would be available at the LTACH facility. The elements of coverage 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 pay for practitioner services provided on February 17, 2023, billed 
with procedure code 01992.  
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed with an inappropriate diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill Medicare for services 
that are not covered as if they are covered.   
We looked at the file and Medicare rules. The claim has not been reported with appropriate diagnosis from the 
list of diagnoses that support medical necessity. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on February 17, 2023, billed with procedure code 01992.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint (27096). 
 
You asked the Plan to pre-approve an injection procedure for sacroiliac joint. You say that the enrollee 
underwent sacroiliacs in the past with 80% improvement. The Plan denied your request. The Plan says this 
request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic SIJI are considered reasonable and 
necessary for patients who meet all of the criteria listed in the Medicare rules section of this letter. 
 
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 an injection procedure for sacroiliac 
joint. Our physician reviewer found there is no documentation of diagnostic maneuvers and recent physical 
therapy or other conservative therapies.  Therefore, the criteria of the LCD are not met and the request, and at 
this time, this 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 an injection procedure for sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint (27096).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 28, 2023, to July 
31, 2023. 
 
You asked the Plan to pay for home health services. You say that you are a network provider with the Plan. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, you billed the services at issue with an 
incorrect Type of Bill. Therefore, we decided that the Plan does not have to pay for home health services 
provided from July 28, 2023, to July 31, 2023.
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 requires LTACH services. The 
Plan denied your request. The Plan says that the enrollee is receiving appropriate inpatient care and is currently 
unstable for 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 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 enrollee is now on room air and has finished intravenous antibiotics. The 
enrollee's wound care is non-complex. Therefore, the enrollee does not meet the LTACH admission criteria. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health stay provided on 
January 22, 2023, to January 26, 2023. 
 
You asked the Plan to waive the copayment for the inpatient mental health stay. You say that you asking what 
you can do to erase this bill. 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 $230 
copayment for inpatient services in a psychiatric hospital.  
You have been asked to pay a $230 copayment for the inpatient mental health stay. This item/service falls 
within the inpatient services in a psychiatric hospital 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. You have been asked to pay a total of $920 for the inpatient 
hospital stay ($230 copayment x 4 days = $920). You have not been charged for the day you were discharged. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient mental health stay 
provided on January 22, 2023, to January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill
(SSBCI).

You asked the Plan to pre-approve SSBCI benefits. You say that you are appealing the SSBCI program denial.
The Plan denied your request. The Plan says the criteria for eligibility have not been met. Maximus overturned
the Plan's denial for lack of information. The Plan requested a reopening and stated that you do not meet
criteria for these benefits and provided medical records for review.

The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a
documented chronic condition that is life threatening or significantly limits the health or function of the
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an
eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive
care management. Therefore, we decided that the Plan does not have to pre-approve special supplemental
benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill
(SSBCI).

You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI
benefits. The Plan denied your request. The Plan says the criteria for eligibility have not been met. Maximus
overturned the Plan's denial for lack of information. The Plan requested a reopening and stated that you do not
meet criteria for these benefits and provided medical records for review.

The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a
documented chronic condition that is life threatening or significantly limits the health or function of the
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an
eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive
care management and are not at high risk for hospitalization. Therefore, we decided that the Plan does not have
to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill
(SSBCI).

You asked the Plan to pre-approve SSBCI benefits. You say that you have chronic obstructive pulmonary
disease, which qualifies you for the SSBCI utility benefit. The Plan denied your request. The Plan says the
criteria for eligibility have not been met. Maximus overturned the Plan's denial because medical records were
not included. The Plan has requested a reopening and provided the Attestation for Special Supplemental
Benefits for the Chronically Ill. The Plan has also shown proof that they requested medical records multiple
times from your treating physician.

The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a
documented chronic condition that is life threatening or significantly limits the health or function of the
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an
eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive
care management and are not at high risk for hospitalization. Therefore, we decided that the Plan does not have
to pre-approve special supplemental benefits for the chronically ill (SSBCI).