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

 
We decided that the Plan does not have to pay for the hospice or home health care provided in patient's 
home/residence (Q5001), physical therapy services in your home (G0151, G0157) provided from September 
10, 2020, to September 30, 2020. 
 
You asked the Plan to pay for the home health services. You say that the enrollee's hospice benefit was revoked 
prior to the dates of service in this case. The Plan denied your request. The Plan says the enrollees claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 4, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospice or home 
health care provided in patient's home/residence (Q5001), physical therapy services in your home (G0151, 
G0157) provided from September 10, 2020, to September 30, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says that there is no proof 
the treatment will benefit lower back pain and spasms. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our physician reviewer found 
that the enrollee has a diagnosis of back pain and muscle spasticity, identified by diagnosis code M62.838.  The 
FDA has stated that the requested drug is indicated for paravertebral administration of Botox to relieve pain 
and improve function. The local coverage determination states that the requested drug is limited to those 
conditions listed in the Local Coverage Article, A57474. The record provided indicates diagnosis code 
M62.838. This is an enumerated diagnosis in the Group 8 code section of A57474. The elements of the 
coverage criteria are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pre-approve Botox.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network SNF care. You say that without skilled nursing, the 
enrollee's health and well-being will continue to decline. You say that the enrollee needs physical and 
occupational therapy and will not be able to get it in a home health setting The Plan denied your request. The 
Plan says the services are available from network 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
SNF care to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for assisted surgery services provided to the enrollee on July 10, 2020.
You asked the Plan to pay for any of these service. You say that this claim 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 states that this case involves an inappropriate billing of code 20936-AS. This code is not supported in the documentation therefore is not payable as the service coded and described in not eligible for assistant surgeon reimbursement.
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 are not eligible for assistant surgeon payment. Medicare rules for coverage of these service have not been met. Therefore, we decided that the Plan does not have to pay for assisted surgery services provided to the enrollee on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the OON provider can provide the 
services the enrollee needs with the most effective options. The Plan denied your request. The Plan says the 
requested provider is an OON provider and there are multiple in-network providers that are available and 
within the enrollee's service area. Therefore, the authorization for service with the OON provider is denied. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee needs to control and record glucose 
numbers to approve surgery. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for approval of the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or 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 CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM) (K0554).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that Keytruda 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 of Keytruda (Pembrolizumab). The Maximus Physician Reviewer determined that Keytruda in combination with Xeloda is medically necessary. The Plan requested a reopen and argues that there is no evidence in the Medicare-approved medical literature to support the efficacy and/or safety of adjuvant pembrolizumab and capecitabine for stage IIIB triple-negative moderately differentiated invasive breast cancer in a member that did not receive pembrolizumab pre-operatively. The Plan notes that the NCCN guidelines do not support adjuvant pembrolizumab in high-risk patients. The Plan is correct in this case. The documentation does not support that the use of Keytruda in this setting is supported by one of the major drug compendia, or by clinical research that appears in a CMS-approved medical journal. NCCN guidelines state that for patients with high-risk HR-negative, /HER2-negative disease, adjuvant Pembrolizumab is indicated if a Pembrolizumab-containing regimen was given preoperatively. Medicare coverage criteria are not met. 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic test strips. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the criteria 
have not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has continuous glucose monitor. The continuous glucose monitor serves the 
same purpose as the requested test strips. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic test 
strips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy visits. 
 
You asked the Plan to pre-approve additional home health physical therapy visits. You say that the requested 
services are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have 
not been met because the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 additional home health physical therapy 
visits. Our reviewer says that the requested services are not medically reasonable and necessary in this case. 
Our physician reviewer found that the available clinical documentation shows that you have functional 
impairments and would likely require skilled therapy to address back pain. However, there is no documentation 
to show that you are homebound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement hospital bed (E1399). 
 
You asked the Plan to pre-approve the replacement hospital bed. You say that the replacement bed is medically 
necessary. The Plan denied your request. The Plan says the enrollee has a hospital bed that is less than 5 years 
old and records do not show it is damaged or unusable. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a hospital bed that was provided in 2020. The replacement bed serves the same 
purpose as the existing bed. Records do not show the existing bed is irreparably damaged. Therefore, we 
decided that the Plan does not have to pre-approve a replacement hospital bed (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on February 19, 2021.
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 are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated the enrollee was seen in subsequent hospital care on February 19, 2021. The submitted documentation supports 1 (one) unit of 99232, which was previously approved and paid. Medicare says services must be verified in the submitted physician documentation. There is no additional documentation supporting an additional study which was billed and remains denied.
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 Plan provided documentation to show these services were previously paid. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the suture services billed for date of service October 20, 
2021. 
 
You asked the Plan to pay for the billed services. You say that the codes are supported in the documentation. 
The Plan denied your request. The Plan says the operative report does not describe the code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27830 is suture of infrapatellar tendon; primary. We find 
that CPT code 27830 is not supported in the medical record. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the suture services billed for date of service October 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service November 4, 
2021. 
 
You asked the Plan to pay for procedure code 99601. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99601 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99601 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99601 billed for date of service November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive LTACH services. The Plan denied your request. The Plan says admission to the LTACH is not 
medically necessary for the condition of the enrollee and the enrollee can remain in the current acute care 
facility for their medical needs. 
 
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 appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be administered at the current facility until 
more appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 24, 2021, to 
December 23, 2021, and billed with Health Insurance Prospective Payment System (HIPPS) code 2BC11. 
 
You asked the Plan to pay for home health services. You say that this is supported in the records. The Plan 
denied your request. The Plan says the records do not support that the billed primary diagnosis (G20, 
Parkinson's disease) was the reason the enrollee required home care, making the appropriate Health Insurance 
Prospective Payment System (HIPPS) code 2FC11 rather than 2BC11. 
 The Plan follows Medicare rules. Medicare rules say that the second position of a Health Insurance Prospective 
Payment System (HIPPS) code represents the clinical domains of the home health resources groups (HHRG) 
coding system, based on the patients principal diagnosis as reported on home health claims. The reported 
principal diagnosis provides information to describe the primary reason for which patients are receiving home 
health services under the Medicare home health benefit. A second digit of B indicates Neuro Rehab and a digit 
of F indicates Behavioral Health. 
 
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 home health services. Our reviewer says that 
the submitted records do not support the billed HIPPS code, 2BC11. Our physician reviewer found there is no 
documentation that the enrollee's diagnosis of G20, Parkinson's disease, was the primary reason for receiving 
home health services. The records document the primary reason for receiving home health services was 
weakness and unstable gait after a recent hospitalization for alcohol abuse and essential tremors. This does not 
fall into the Neuro Rehab clinical group. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided from November 24, 2021, to December 23, 2021, and 
billed with Health Insurance Prospective Payment System (HIPPS) code 2BC11.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on April 11, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the date the specimen was 
collected (March 28, 2022) does not match the date of service billed. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic testing (81479) provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2022 to June 17, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 21, 2022 to June 17, 2022.