Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that it would be difficult to get an objective second 
opinion. The Plan denied your request. The Plan says services can be provided through the Plan's pulmonology 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
pulmonary services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery. 
 
You asked the Plan to pre-approve these services. You say that this procedure is very important because 
currently you are not able to walk because the pain is excruciating. The Plan denied your request. The Plan says 
that experimental and investigational procedures are not covered by Medicare. 
 
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. The device is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your 
condition does not meet Medicare criteria for 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 Vertiflex Superion device placement surgery.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay for pathology interpretation provided to the enrollee on September 19, 2019 under codes 88305-26 and 88173-26. 

You asked the Plan to pay for this claim as billed. You say that this service should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan states that this claim denied because the Plan previously paid for these services under another claim. The Plan paid the treating hospital for this service as it was showing the performed the professional component of the service. The case file includes the Explanation of Remittance that shows the Plan paid $153.43 to the providing hospital on October 4, 2019 for this service. The reimbursement of the global procedure code represents reimbursement  for both the professional and technical components of the code. The Plan states because they reimbursed the global procedure, the payment is complete. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the services billed were included with the global procedure code billing by the providing hospital and cannot be billed to the Plan separately. Medicare billing criteria are not met. Therefore, we have decided that the Plan does not have to pay for pathology interpretation services billed to the enrollee for September 19, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to provide coverage for Herceptin.
You asked the Plan to provide coverage for Herceptin. You say that this drug is medically necessary. The Plan
denied your request. The Plan stated Medicare coverage criteria were 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. Our Medical Director says at issue is
coverage for Herceptin (Trastuzumab). The Maximus Physician Reviewer determined that the requested drug is
FDA-approved for the enrollee's diagnosis. The reviewer stated that it is not unusual to substitute Paclitaxel for
Docetaxel, given the side-effect profile and risk-to-benefit profiles based on comorbidities and desired side
effects. The Plan requested a reopen stating the requested drug is being used in a four-drug regimen that is not
FDA-labeled nor supported by one or more citations in Medicare approved compendia or peer -reviewed
medical literature in CMS-approved journals or publications. Based on the medical records provided, the Plan
is correct in this case. The proposed regimen was Pertuzumab, Trastuzumab, Paclitaxel, and Carboplatin.
The regimen of Pertuzumab, Trastuzumab, Paclitaxel, and Carboplatin is not supported in the compendia or the
medical literature at this time. Medicare coverage criteria are not met.
We looked at this review and the Medicare rules. Based on this information, we have now decided the
Medicare coverage criteria are not met for the use of the requested drug. Therefore, it is now our decision that
the Plan does not have to provide coverage for Herceptin.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe non-emergency ambulance services and ground mileage (A0425, A0428) provided on June 11, 2019.You asked the Plan to waive the copayment forthe non-emergency ambulance services and ground mileage. You say that you would like this claim reprocessed and the copayment waived.The Plan denied your request. The Plan says the copayment has processed correctly and no reimbursement is due.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $265 copayment for ambulance services. The enrollee has been asked to pay a $265 copayment for the non-emergency ambulance services and ground mileage. The services provided fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe non-emergency ambulance services and ground mileage (A0425, A0428) provided on June 11, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is 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 above 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required supervision to sit 
up, stand up, transfers and walking to fifty feet with two turns. The enrollee was independent with eating and 
oral hygiene. The documentation does not support that the enrollee requires the specialized skills, knowledge, 
or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically 
necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy 
services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services 
on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palliative treatment of dental pain (D9110). 
 
You asked the Plan to pre-approve the dental service. You say that you have an infection from your crown. 
You say that you are in a lot of pain. You say that you cannot afford to pay $50 for palliative treatment. You 
also say that you cannot eat properly and cannot sleep with the pain. The Plan denied your request. The Plan 
says palliative treatment of dental pain is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
palliative treatment of dental pain (D9110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Dexcom G6 Continuous Glucose Monitor (CGM), sensors, and supplies.

You asked the Plan to pre-approvethe CGM, sensors, and supplies. You say that the enrollee had an accident at work a year ago that affected his hand and resulted in paresthesia and decreased strength and mobility. You say that the enrollee cannot manage his normal glucometer. As a result,he has been unable to monitor his glucose.The Plan denied your request. The Plan says the enrollee does not meet the Medicare rules for continuous glucose monitoring.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMS and related supplies are covered when certain 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 pre-approve the CGM, sensors, and supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is not treated with insulin. Although there are extenuating circumstances that make it hard for the enrollee to use the glucometer, the guidelines for coverage do not call for blood glucose monitoring in patients with T2. Especially in cases like the enrollee's, where the control appears to be excellent with an A1C of 6.5% while on a medication which does not cause hypoglycemia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvethe requested device. You say that you prick your finger 5 times a day.The Plan denied your request. The Plan says you have not met all the requirements to obtain a continuous glucose monitor.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentationdoes not indicatethat you require frequent self-adjustment of insulin based on testing results.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Gemcitabine (J9201). 
 
You asked the Plan to pre-approve Gemcitabine. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gemcitabine. Our reviewer says that 
the service is medically necessary. Our physician reviewer found Gemcitabine has shown modest activity 
making the use of this drug 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 Gemcitabine have been met. Specifically, this service is found to be medically 
necessary and reasonable. Therefore, we decided that the Plan has to pre-approve Gemcitabine (J9201).  
 
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 pre-approve a DexCom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve a DexCom G6 CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a DexCom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a DexCom G6 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Freestyle Libre 14 day reader for the enrollee. 
 
You asked the Plan to pre-approve the reader. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no log showing adjustment of insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered if there 
is a diagnosis of diabetes mellitus, the enrollee has been testing four times a day, the enrollee is insulin-treated, 
and this treatment requires frequent adjustment on the basis of testing results. 
 
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 reader. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee checks blood sugar multiple times daily, and is on insulin multiple times daily. Clearly, 
some decision is being made on dosing, or it would not be checked at this frequency. The enrollee has diabetic 
neuropathy - a complication of diabetes. This can be managed better with better glycemic control, which the 
requested reader can facilitate. 
 
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 reader have been met. Therefore, we decided that the Plan has to pre-
approve the Freestyle Libre 14 day reader for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve a dental extraction to be performed by an oral surgeon. 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. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental extraction to be performed by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysa review of the current medical literature indicates that this service is 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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. There is no spinal instability. The hardware is not needed.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are a recent amputee and need rehab to learn how to walk again and how to function without a leg.The Plan denied your request. 

The Plan says the clinical information does not show that the guidelines for coverage of IRF care have been met. The Plan says that the enrollee's needs can safely be met at a skilled nursing facility or at home with home health services.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 needsdoes not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a COVID-19 infection and infection of recent left lower extremity vascular graft. Left above the knee amputation was performed. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) for all four
quadrants.
You asked the Plan to pre-approve the dental services. You say that the enrollee has active periodontitis
evidence of bone loss with pockets measuring up to 6mm. You also say that periodontal scaling and root
planing for all four quadrants is recommended. The Plan denied your request. The Plan says that there is no
evidence of significant bone loss. The Plan also says that the scaling and root planing is not medically
necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says
that the periodontal scaling and root planing for all four quadrants is medically necessary. Our physician
reviewer found the provided documentation indicates the presence of pathological periodontal pockets in all
quadrants, presence of horizontal bone loss and calculus accumulation. Therefore, the reviewer found that
periodontal scaling and root planing is reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to
pre-approve periodontal scaling and root planing (D4341) for all four quadrants.
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.