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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee has progressed through several lines of 
therapy. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition. 
 
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 Keytruda. Our physician reviewer 
found that the enrollee has a diagnosis of serous ovarian cancer of Mullerian origin that is not microsatellite 
instability-high (MSI-H) or mismatch repair deficient (dMMR), or tumor mutational burden-high (TMB-H) 
tumors =10 mutations/megabase. The FDA has not stated that the requested drug is indicated for the enrollee's 
condition.  The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral lumbar medial branch blocks (MBBs) for the enrollee.
You asked the Plan to pre-approve the MBBs. You say that the MBBs are medically necessary. The Plan denied your request. The Plan says that the medical records do not document a failure to respond to noninvasive conservative management.
Our Medical director looked at the case file and the reopen request. At issue is coverage for MBBs. Our Medical Director states that the documentation does not support that there has been documented failure to respond to noninvasive conservative management of the enrollee's spondylosis and radiculopathy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the MBBs. 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 MBBs have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral lumbar medial branch blocks (MBBs) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care services provided to the enrollee from January 13, 2022, to January 28, 2022.
You asked the Plan to pay for the home health care services. You say that the Notice of Admission (NOA) for this claim was submitted on January 13, 2022, and you would like this claim to be reprocessed. The Plan denied your request. The Plan says the NOA was not received.
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care. In this case, the start of care date is January 13, 2022. The NOA was not received by the Plan. As there is no NOA included in the documentation provided, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care services provided to the enrollee from January 13, 2022, to January 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 22, 2022, to May 18, 2022.
You asked the Plan to pay for the home health services as billed. You say that you have submitted a Notice of Admission (NOA). The Plan denied your request. The Plan says the claim has not been billed with the correct admission date.
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA. We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 22, 2022, to May 18, 2022.
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. You say that BiPAP is insufficient to stabilize the enrollee. The 
Plan denied your request. The Plan says Medicare does not cover ventilators for the requested use. 
 
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 the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease.  The record indicates that the enrollee was successfully treated with BiPAP. The provided documentation does 
not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with advanced volume-assured pressure support (AVAPS) capability.  
The Plan has indicated it would approve such a device is available upon request. The elements of the coverage 
criteria are not satisfied. Therefore, 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids and the hearing aid 
earmolds purchased on May 5, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were not purchased from the Plan's select hearing aid provider. Additionally, hearing aid earmolds are 
not a covered benefit.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids are covered 
only when purchased through the Plans select hearing aid provider.  However, the hearing aids in this case were not purchased from the Plans select hearing aid provider. 
Additionally, hearing aid earmolds are not a covered benefit. Therefore, we decided that the Plan does not have 
to issue reimbursement for the hearing aids and the hearing aid earmolds purchased on May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on May 9, 2022.
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and approved for payment as the procedure code is eligible for payment according to Medicare rules. The Plan denied your request. The Plan says that required information was not received by the Plan.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. The Plan requested medical records on multiple occasions without response. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingivectomy or gingivoplasty to allow access for restorative 
procedure (D4212) provided on September 29, 2022. 
 
You asked the Plan to pay for gingivectomy or gingivoplasty to allow access for restorative procedure. You say 
that this should be covered. The Plan denied your request. The Plan says this is not 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 Plans 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 pay for 
gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) provided on September 29, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical technicians agreed you had a classic panic attack. You also say they suggested you go to 
the hospital but you felt better so you remained at home. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0428, A0425) provided to the enrollee on December 24, 2021.
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the enrollee was receiving the hospice benefit at the time of service.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0428, A0425) provided to the enrollee on December 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with field of view 
of one full dental arch  mandible (D0365), and consultation - diagnostic service provided by dentist or 
physician (D9310) provided on November 11, 2022. 
 
You asked the Plan to pay for codes D0365 and D9310. You say that the dentist is an approved provider. You 
also say this service was to check on a root pain of your molar. The Plan denied your request. The Plan says the 
two services you received are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for cone 
beam CT capture and interpretation with field of view of one full dental arch  mandible (D0365), and 
consultation - diagnostic service provided by dentist or physician (D9310) provided on November 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission as acute rehabilitation is medically necessary, reasonable and appropriate. The Plan denied 
your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this service will help the enrollee to gain 
the desired mobility with the goal of returning home. The Plan denied your request. The Plan says the enrollee 
can stay in the hospital until they are safe for transfer or discharge. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute critical care services. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need more time trying to get return of strength. 
The Plan denied your request. The Plan says your request does not meet the guidelines because you no longer 
require skilled services, and the continuation of a skilled nursing facility 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 in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from February 25, 2022, to February 27, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. 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 information. The Plan noted an error in the case file stated this was inpatient care which is incorrect. The Plan is upholding the claim line denials as a status indicator "C" inpatient procedure code 22846 was billed on an outpatient claim. Code 22846 is considered an inpatient only code. In addition, the enrollee did not expire during surgery and this code 22846 would not meet an exception requirement.
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 code. In this case this claim could not be paid as billed because an inpatient only code was billed on an outpatient claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from February 25, 2022, to February 27, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided to the enrollee on February 14, 2022.
You asked the Plan to pay for the lab testing services. You say that the testing would be used to determine the course of treatment for the enrollee. The Plan denied your request. The Plan says that appending modifier TC is incorrect.
The Plan must follow Medicare rules. Medicare rules say that the Professional Component (PC)/Technical Component (TC) Indicator of 9 means the concept of a professional/technical component does not apply. We find that CPT code 85027 has a Professional Component (PC)/Technical Component (TC) Indicator of 9. In this case CPT coded was billed with a TC modifier incorrectly. Based on this information, we decided that Medicare rules for coverage of the lab testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided to the enrollee on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on March 15, 2022.
You asked the Plan to pay for the laboratory services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the required unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on February 24, 2022.
You asked the Plan to pay for the F1CDx testing. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the required unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. Based on this information, we decided that Medicare rules for coverage of the F1CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on February 24, 2022.