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

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the criteria for approval have not been 
met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has rehabilitation needs but by clinical practice standards the enrollee has 
daily skilled therapy needs. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: 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 the enrollee cannot fully function at home without 
assistance.  The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been 
met.  
 
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 there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 
The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that 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 medically reasonable and necessary. Our physician reviewer found the enrollee has 
skilled nursing needs and the rationale for denial is not supported in the records. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve home health services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on April 12, 
2022, to May 04, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you do not agree with the 
cost share applied for injection received. 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 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs. This item/service falls within the 
Medicare Part B Prescription Drugs 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. The total you owe is $1,320.02, which is 20% of the allowed amount for 
chemotherapy injectable drug, pertuzumab. Therefore, we decided that the Plan does not have to waive the 
coinsurance for chemotherapy drugs provided on April 12, 2022, to May 04, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one. 
 
You asked the Plan to pre-approve Gel-one. You say that the requested Gel-one is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Durolane, Monovisc, OR Synvisc-One 
first.  
 
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 Gel-one. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Durolane, Monovisc, OR Synvisc-One first before they will approve the requested drug. In this case the 
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the 
Plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The 
Plan denied your request. The Plan says the requested Retacrit is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Retacrit. Our reviewer says that the 
requested Retacrit is not medically necessary. Our physician reviewer found the case file lacks recent 
laboratory testing regarding the anemia. There is no documented need to decrease the need for red blood cell 
transfusion.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
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 need the rehabilitation due to a bone disorder 
with a rare presentation. The Plan denied your request. The Plan says the IRF care is not medically necessary, 
and your needs can be met at a lower level of care, such as a skilled nursing facility, home with home health 
services, or home with outpatient therapy. 
 
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 were admitted for a femur fracture. Your medical problems are stable, and there 
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87500, 87641, 87798, G0452, 87491, 87496, 
87511, 87529, 87532, 87653, 87591, 87661, 87481, 87651, 87653) provided on July 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87500, 87641, 87798, G0452, 87491, 87496, 
87511, 87529, 87532, 87653, 87591, 87661, 87481, 87651, 87653) provided on July 18, 2022.  
 Maximus read your letter and knows that you may have a question regarding your enrollment in the Plan. 
Maximus cannot answer enrollment questions. Maximus is sending a copy of your case file and your letter to 
the Philadelphia CMS Regional Office so that it can look into your enrollment question.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF test provided on December 11, 2022. 
 
You asked the Plan to pay for the Tempus xF test. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF test have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF test provided on 
December 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 13, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya.  
You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your 
request. The Plan says a trial of Inflectra or Remicade is required first. 
 
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 Ilumya. Our reviewer says that Ilumya 
is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) (37229). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria. 
 
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 service Our physician reviewer 
found at issue is the medical appropriateness and necessity of PTA. The enrollee has evidence of lower 
extremity peripheral vascular disease (PVD), but symptoms are not lifestyle-limiting, with records indicating 
ability to walk up 7 flights of stairs. Moreover, documents do not confirm that direct ankle-brachial index 
(ABI) assessment has been performed. As such, guidelines for PTA are not met. In summary, there is 
insufficient documentation to support the medical necessity for PTA in this enrollee's 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transluminal angioplasty (PTA) (37229).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing exam provided on February 02, 
2023. 
 
You asked the Plan to waive the copayment for hearing exam. You say that you want to appeal the amount 
being charged. 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 $45 
copayment for hearing services. 
 
You have been asked to pay a $45 copayment for hearing exam. This item/service falls within the hearing 
services 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 hearing exam provided on 
February 02, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from June 10, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 require skilled nursing or therapy services on a daily basis. You do not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the continuation of skilled nursing facility (SNF) care from June 10, 2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Proteor Shockwave Prosthetic K3 foot (L5987, L598). 
 
You asked the Plan to pre-approve a Proteor Shockwave Prosthetic K3 foot. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 Proteor Shockwave Prosthetic K3 
foot. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
physician documentation does not support that the enrollee is participating in high impact activities that would require a shock reducing pylon. The prosthetist is the vendor and recommends the shock reducing feature, but 
this is not supported in the physician documents. The requested foot with shock reducing pylon exceeds the 
enrollee's needs.  
 
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 Proteor Shockwave Prosthetic K3 foot have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Proteor Shockwave Prosthetic K3 foot (L5987, L598).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested use of Botox to treat gastroparesis is 
medically necessary.  The Plan denied your request. The Plan says the requested use of Botox to treat 
gastroparesis is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the 
requested use of Botox to treat gastroparesis is not medically necessary.  Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of gastroparesis. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on January 17, 2023. 
 
You asked the Plan to pay for emergency room services. You say that the services were medically necessary. 
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 emergency room 
services provided on January 17, 2023.