Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
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 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 SSBCI benefits. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found you have a documented and active 
diagnosis for one or more of the qualifying comorbid and medically complex conditions. Our reviewer also 
found that there is no documentation provided indicating you require intensive care management or are at high 
risk for hospitalization. 
 
 We looked at this physician's review, 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. Therefore, we decided that the Plan does not 
have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
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 services are medically necessary for 
the enrollee to receive the appropriate level of care. The Plan denied your request. The Plan says the enrollee's 
medical record shows that they do not meet Medicare guidelines for admission. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The health plan has approved ongoing care in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
failed the preferred agent. 
 
 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 Evenity. Our physician reviewer found 
that the enrollee has osteoporosis. The Plan requires a trial of Forteo before they will approve the requested 
drug. There is no indication that the enrollee has tried and failed the required drug. There is no indication that 
the Plan's required drug would likely be less effective 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flow cytometry (88185, 88184, 88188) provided on 
November 24, 2021. 
 
You asked the Plan to pay for the flow cytometry. You say that these are billable and payable codes. The Plan 
denied your request. The Plan says the enrollee does not have a covered indication for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that flow cytometry will only be covered for 
indications listed in the LCD and LCA. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has a covered 
diagnosis according to the associated LCD and LCA. Based on this information, we decided that Medicare 
rules for coverage of the flow cytometry have not been met. Therefore, we decided that the Plan does not have 
to pay for the flow cytometry (88185, 88184, 88188) provided on November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 19, 2021, to 
August 20, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis A41.9, described as sepsis, 
unspecified organism, and secondary code R65.20, described as severe sepsis without septic shock. 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 at the DRG originally 
billed. Our reviewer says that documentation does not support the billed codes. Our physician reviewer found 
the enrollee was admitted with a diverticular abscess and met criteria for Systemic inflammatory response 
syndrome (SIRS). Her condition did not include hemodynamic, renal, hepatic, hematologic, respiratory, or 
neurological criteria for sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 19, 2021, to August 20, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
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 the LTACH services. You say that the enrollee would not get adequate care 
in a lower-level setting. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 benefits available that you have not 
used, and would like to appeal for your SSBCI benefits. The Plan denied your request. The Plan says the 
criteria for eligibility have not been met. 
 
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. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
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. The Plan denied your request. The Plan says the enrollee does not 
have complex medical needs that require oversite at least 3 times weekly physical medicine and rehabilitation 
provider, a skilled nursing facility can safely meet the current medical, and therapy needs. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has not had long lasting 
relief from injections. The Plan denied your request. The Plan says the device is contraindicated for the 
enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that the requested device is considered experimental. More research is needed to show its safety 
and efficacy. Therefore, the request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says the requested 
therapy is available on a BiPAP device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that you have a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary 
disease. The records document that the home ventilator is being requested for use in a pressure support mode 
which could be provided by a BiPAP device with average volume assured pressure support (AVAPS) and a 
back-up rate. The records do not document trial and failure of a BiPAP device. Ventilators used to provide 
BiPAP therapy are not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that bi-level positive airway pressure has been ruled out. 
The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw  
(CPT 70100), a swallowing function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck 
(CPT 70310), an upper gastrointestinal tract x-ray (CPT 74240), and an office or other outpatient visit for the 
evaluation and management of a new patient (CPT 99204) provided on November 17, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing 
function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck (CPT 70310), an upper 
gastrointestinal tract x-ray (CPT 74240), and an office or other outpatient visit for the evaluation and 
management of a new patient (CPT 99204). You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were performed at a nursing home 
(via mobile van/portable x-ray), which are denied as an excluded place of service. 
 
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 neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing function x-ray 
(CPT 74230), diagnostic radiology procedures of the head and neck (CPT 70310), an upper gastrointestinal 
tract x-ray (CPT 74240), and an office or other outpatient visit for the evaluation and management of a new 
patient(CPT 99204) have not been met. Therefore, we decided that the Plan does not have to pay for a 
neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing function x-ray (CPT 74230), 
diagnostic radiology procedures of the head and neck (CPT 70310), an upper gastrointestinal tract x-ray  
(CPT 74240), and an office or other outpatient visit for the evaluation and management of a new patient 
(CPT 99204) provided on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro powered arm brace. 
 
You asked the Plan to pre-approve MyoPro powered arm brace. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
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 MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had a traumatic brain injury in 2008 resulting in left upper 
extremity partial paralysis. The enrollee has engaged in physical therapy, occupational therapy, and Botox for 
his upper extremity weakness and remains with persistent functional deficits and inability to carry out activities 
of daily living independently. The MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee.  There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 
Therefore, the enrollee does not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve MyoPro powered arm brace.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for procedure code 88360 for date of service September 21, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus overturned our decision stating we determined that procedure code 88360 is the more comprehensive Column One code to Column Two code 88342. A Column One code cannot be bundled into a Column Two code and that the Plan has not provided a valid denial rationale. The Plan notes that review of the enrollee's claim history found a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between code 88360 and 88342. The Plan provided the NCCI edit page that reflects this edit and states Maximus applied the incorrect billing criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, code 88360 could not be paid as billed due to the NCCI edit relationship to code 88342. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88360 for date of service September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the laboratory services and CT scan 
provided from September 25, 2021, to September 28, 2021. 
 
You asked the Plan to waive the coinsurance for the lab services and CT scan. You say that you thought you 
had met your out-of-pocket maximum before this date. 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 15% 
coinsurance for in-network outpatient laboratory services. Your contract with the Plan also clearly says that you must pay 15% coinsurance for in-network outpatient diagnostic radiology services. 
 
The records show your maximum out-of-pocket was met during the processing of this claim and you have been 
asked to pay a total of $28.78. You have been asked to pay 15% coinsurance of the allowed amount for each 
laboratory service. You have also been asked to pay up to 15% coinsurance of the allowed amount for the CT 
scan. These items/services fall within the outpatient diagnostic tests and therapeutic 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 coinsurance for the laboratory services and diagnostic radiology services 
provided from September 25, 2021, to September 28, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of methadone; up to 7 additional day 
supply, list separately in addition to code for primary procedure (G2078) provided on November 7, 2022, by an 
out-of-network (OON) provider.  
You asked the Plan to pay for the opioid treatment services. You say that you believe that the Plan did not have 
all of the necessary information to process your claims correctly. The facility has been enrolled in the Medicare 
program to provide OTP services since January 1, 2020. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider. This provider was not certified/eligible to be 
paid for this procedure. Payment is not allowed for this claim because it does not meet the opioid treatment 
program criteria for payment. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. The claim was billed naming the doctor as the rendering provider. An individual provider 
cannot bill for OTP services. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for the take-home supply of 
methadone; up to 7 additional day supply, list separately in addition to code for primary procedure (G2078) 
provided on November 7, 2022, by an out-of-network (OON) provider.