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

We decided that the Plan does not have to pre-approve Vecitibix (panitumumab) for the enrollee.

You asked the Plan to pre-approve Vecitibix (panitumumab). You say that this drug is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Vectibix
(panitumumab) in combination with other drugs. The Maximus Physician Reviewer determined that the
enrollee has rectal cancer. The documentation does not support that the requested drugs are FDA-approved for
the enrollee's diagnosis. However, the requested use is supported in a major drug compendium or by clinical
research that appears in a CMS-approved medical journal. Although not preferred regimen, it is an acceptable
alternative regimen based on ESMO guidelines even with enrollees that have progressed on prior epidermal
growth factor receptor (EGFR) therapy. Therefore, the requested drugs are safe, effective, reasonable, and
necessary for the enrollee. The Plan has requested a re-opening, citing an error on the face of the evidence. The
plan has stated that it disagrees with our consultant's determination. The Plan argues that there is "no
established evidence to support the use of Vecitibix (panitumumab) as subsequent therapy for metastatic
colorectal cancer after prior progression on Vecitibix (panitumumab)."

Our Medical director has concluded that the Plan is correct in this case. There is insufficient evidence to
support the use of an EGFR antibody if a patient has been refractory to one of the EGFR antibodies. In this
case, there was evidence of disease progression on the EGFR antibody panitumumab. We looked at this
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Vecitibix (panitumumab) have not been met. Therefore, we decided that the Plan does not have to
pre-approve Vecitibix (panitumumab) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 3 home health occupational therapy (OT) visits.

You asked the Plan to pre-approve the additional home OT visits. You say that it is felt that the enrollee would benefit from more OT sessions. The Plan denied your request. The Plan says the requested additional visits 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 the additional home OT visits. Our reviewer says that the requested additional OT services are not shown to be medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with a history of stroke and vascular dementia. She has been receiving home health services since 4/8/2021. Based on the most recent OT records, the enrollee appears to have reached a plateau in function. Ongoing OT is not necessary to maintain her condition or prevent deterioration.

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 additional home OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 3 home health occupational therapy (OT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (CPT code E2300), for the enrollee.
You asked the Plan to pre-approve a power seat elevation system. You say that the power seat elevation system is necessary. The Plan denied your request. The Plan says a power seat elevation system is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Medicare does not consider the power seat elevation to not be medical in nature and therefore it is not covered. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (CPT code E2300), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee.

You asked the Plan to pre-approve these services. You say that the enrollee is in pain. The Plan denied your request. The Plan says that the clinical value and effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliitis has 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. This procedure is considered experimental/investigational because of the wide efficacy reported in the literature. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says needs can be met in other settings.

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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no documented skilled nursing
or skilled therapy needs. The enrollee is currently limited by their weight-bearing status. Daily skilled services
are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs, as a practical matter, 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 Power Mobility Device (PMD).

You asked the Plan to pre-approve the PMD. You say that the claim should be paid, that you need the PMD. The Plan denied your request. The Plan says the documentation provided does not show a mobility assessment was completed.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs shown in the documentation provided. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 Power Mobility Device (PMD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services (37607, 36902, 36907) provided January
21, 2020.
You asked the Plan to pay for the surgery services. You say that you would like these claims reprocessed for
medical necessity. The Plan denied your request. The Plan says Medicare guidelines state that an assistant
surgeon may not be paid for these procedures.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 37607, 36902, 36907. The Medicare Fee Schedule Database contains a
surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is
not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgery services have not been met. Therefore, we decided that the Plan does not have to pay for
the surgery services (37607, 36902, 36907) provided January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on July 1, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid as it is not your issue that
another provider made an additional submission. The Plan denied your request. The Plan says the surgery
center billed the claim on a UB-04 incorrectly and should have billed on a CMS-1500. Until both claims are
corrected neither can be paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and use the appropriate forms. In this case this claim
cannot be paid as billed due to an error on the form and the type of form submitted. Therefore, we decided that
the Plan does not have to pay for medical services provided to the enrollee on July 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol.

You asked the Plan to pre-approve Tramadol. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Tramadol.

Benefits for Tramadol 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 pay for the skilled nursing facility (SNF) level of care in a swing bed
unit provided from January 24, 2021, to January 31, 2021.
You asked the Plan to pay for the SNF care. You say that the services were necessary. You also say that you
had tried to obtain preauthorization. The Plan denied your request. The Plan says the services provided were
not medically necessary.
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 pay for the SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing
needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee
did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a
skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the SNF care have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) level of care in a swing bed unit provided from January 24,
2021, to January 31, 2021.
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 it is not safe for the enrollee to return home and the enrollee requires advanced level of care not available at a lower level. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861).

You asked the Plan to pre-approve a Group 3 PMD. You say that the enrollee requires the device to be mobile.
The Plan denied your request. The Plan says the enrollee cannot safely operate a PMD.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

The file shows that the enrollee's condition can be improved by a walker, cane or manual wheelchair and they
cannot safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair
(K0861).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on January 20, 2021, through February 3, 2021.

You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because the services rendered support DRG 727. The Plan denied your request. The Plan says community acquired pneumonia is unable to be verified.

The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been 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 pay for the inpatient hospital services. Our reviewer says that there is insufficient evidence in the documentation submitted to support community acquired pneumonia. Our physician reviewer found the record does not show that the member had any respiratory signs or symptoms on exam to suggest pneumonia. 

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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on January 20, 2021, through February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided December 9, 2020, to December 16, 2020, and inpatient rehabilitation care provided December 16, 2020, to December 24, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care and inpatient rehabilitation care. You say that you do not believe you should be charged for two separate hospital stays. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $350 copayment per day, days 1-5 and a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a total cost share of $1750 for the inpatient hospital care and a total cost share of $1750 for inpatient rehabilitation care. These services fall within the inpatient hospital care benefit category. Although you remained in the same facility, you transferred between levels of care resulting in a second copayment. 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 the inpatient hospital care provided December 9, 2020, to December 16, 2020, and inpatient rehabilitation care provided December 16, 2020, to December 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for routine transportation beyond the 30-mile limit.

You asked the Plan to provide coverage for an exception to the 30-mile limit for routine transportation. You
say that this exception is necessary for you to see a provider. The Plan denied your request. The Plan says
exceptions are not made to supplemental benefits. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated the QIC did not apply the correct contract information.

The Plan is correct in this case. 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 Plan's
coverage rules apply in this case. You are asking to be taken to a location beyond the transportation benefit
limit of 30 miles. Exceptions are not made to supplemental benefits. Therefore, we decided that the Plan does
not have to provide coverage for routine transportation beyond the 30-mile limit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography permission (CTP) of the brain
(004T) for the enrollee.

You asked the Plan to pre-approve CTP of the brain. You say that CTP of the brain is medically necessary for
the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
LCD Criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules state that CTP is covered
for enrollees who have had a stroke. The medial records provided do not show the enrollee has had a stroke.
Whether or not the service is beneficial for the enrollee is not of issue. The rules are clear that the criteria must
be met in order to be covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve
computed tomography permission (CTP) of the brain (004T) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this treatment is considered safe and effective, as supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical evidence with numerous peer reviewed studies. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.