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

 
We decided that the Plan does not have to pre-approve a next generation sequencing panel. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that NGS panels are covered when specific criteria 
are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has multiple myeloma not 
having achieved remission. The documentation does not support that the Quest Diagnostics Myeloid Mutation 
Analysis Profile next generation sequencing panel has Food and Drug Administration (FDA) approval or FDA 
clearance as a companion in vitro diagnostic, and an FDA-approved or FDA-cleared indication for use in this 
enrollee's cancer. 
 
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 a next generation sequencing panel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from October 25, 2021, 
to November 1, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that there was nowhere else for the 
enrollee to go while you were awaiting a hospice bed. The Plan denied your request. The Plan says the 
inpatient hospitalization was no longer medically necessary after October 24, 2021. 
 
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 pay for the inpatient hospital services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient was a 97 year-old female who was admitted with an ischemic stroke on 
October 10, 2021.  Her care as of October 24, 2021, was for comfort measures only and she was awaiting 
transfer to a long term care facility with hospice services.  The continued inpatient services from October 25, 
2021, to November 1, 2021, were not medically 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided from October 25, 2021, to November 1, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on March 17, 2022, to March 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available who could have provided these 
services. 
 
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. 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 physical therapy provided on March 17, 2022, to 
March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection and office visit provided on 
April 4, 2022. 
 
You asked the Plan to waive the cost share for an injection and office visit. You say that you weren't aware of 
how much the injection would cost if you were you never would have had it done. The Plan denied your 
request. The Plan says the cost share applied is correct. 
 
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 20% 
coinsurance for Medicare covered Part B drugs and a $5 copayment for an office visit.  
 
 
 
 You have been asked to pay $1,058 which is 20% of the allowed amount for an injection. The allowed amount 
is $5,291.10 (20% x $5,291.10= $1,058). The total for the injection and office visit is $1,063.22. The injection 
falls within the Medicare Part B Prescription Drugs benefit category. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 cost share for an injection and office visit provided on April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on January 27, 2022, by an 
OON provider. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that does not require authorization and have not been included in any other billing to treat the wounds 
described in the attached medical records documentation. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 
 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. 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 wound care supplies provided on January 27, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care you received on March 9, 2022. 
 
You asked the Plan to pay for routine foot care. You say that you had corns and calluses that were causing you 
pain.  You said that you tried over-the-counter medications, but they did not work.  You said that your only 
option was to go to a podiatrist, and you did not realize this would not be covered. The Plan denied your 
request. The Plan says routine foot care is not covered except for patients certain medical conditions. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
 
 
 
 
 
 
 Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot 
care you received on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical and vaginal cancer screening you received on 
March 28, 2022. 
 
You asked the Plan to pay for the cervical and vaginal cancer screening. You say that the doctor should have 
checked before providing this service and it is not your fault that you did not know this was covered only every 
two years. The Plan denied your request. The Plan says you were not eligible for a cervical and vaginal cancer 
screening on this date. 
 
The Plan must follow Medicare rules. Medicare rules say that cervical and vaginal cancer screenings are 
covered every 24 months.  This time restriction is also reiterated in your Evidence of Coverage.  Records show 
that you last had a covered cervical and vaginal cancer screening in March of 2021, so you were not eligible for 
another one on the date of service in question in this appeal. We looked at the file and Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the cervical and vaginal cancer screening have 
not been met. Therefore, we decided that the Plan does not have to pay for the cervical and vaginal cancer 
screening you received on March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standard wheelchair (k0001) provided on February 17, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wheelchair. You say that the item should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the item denied correctly as they were non-emergent and 
prior authorization was not obtained. 
 
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. 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 a standard wheelchair (k0001) provided on 
February 17, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you want to try Prolia. The Plan denied your request. 
The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of an 
intravenous bisphosphonate such as zoledronic acid before it will approve Prolia. 
 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 Prolia. Our reviewer says that you do 
not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found you have 
not tried and failed the Plan's preferred drug of zoledronic acid. The record does not show that this drug would 
likely be less effective or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Prolia.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit (99285) provided on September 
25, 2021. 
 
You asked the Plan to pay for the physician service. You say that you received a refund request for the 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. 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 emergency room visit (99285) provided on September 25, 
2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve K3 prosthetic components (L5822, L5845, L5850, L5979). 
 
You asked the Plan to pre-approve the K3 prosthetic components. You say that these components are medically 
necessary. The Plan denied your request. The Plan says that the requested features exceed the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of prosthesis. 
 
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 K3 prosthetic components. Our 
reviewer says that the requested prosthesis is medically necessary. Our physician reviewer found the 
documentation specifically shows that patient meets K3 level functionality. Documentation also shows that 
patient has good strength and requires a prosthetic to help navigate variable surfaces with variable cadences. 
 
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 K3 prosthetic components have been met. Therefore, we decided that the 
Plan has to pre-approve K3 prosthetic components (L5822, L5845, L5850, L5979).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block provided on August 5, 2021. 
 
You asked the Plan to pay for a genicular nerve block. The Plan denied your request. The Plan says a genicular 
nerve block 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 pay for a genicular nerve block. Our reviewer says 
that a genicular nerve block is not considered medically reasonable and necessary. Our physician reviewer 
found that genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are considered experimental/ 
investigational in nature. The genicular nerve block was not reasonable or medically 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pay for a genicular nerve block provided on August 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services after April 24, 2022.
You asked the Plan to provide coverage for SNF services. You say that at the time of the appeal, SNF services were medically necessary.
The Plan denied your request. The Plan says as of April 22, 2022, you no longer met the Medicare coverage criteria for SNF services and were given notice that your coverage would end on April 24, 2022. Maximus overturned the Plans denial because a copy of this notice was not included in the case file. The Plan requested a reopen and provided a copy of the notice you signed on April 22, 2022.
Based on review of the medical records, the Plan was correct in their denial of continued coverage. 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. The medical records show that as of April 22, 2022, you no longer required daily skilled nursing or daily skilled therapy services provided at an inpatient level of care. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) services after April 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 15, 2022, by an 
OON provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing and have submitted records 
to support medically necessity of the services rendered on this date of service. The Plan denied your request. 
The Plan says the out-of-network services were not authorized. 
 
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. 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 laboratory services provided on February 15, 
2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for hospital services provided to the enrollee coded as 76942.
You asked the Plan to pay this claim as billed. You say that this service should be covered by the Plan. 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 that Maximus did not apply the correct billing criteria.
The Plan also submitted additional claim information. The Plan demonstrated a National Correct Coding
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 76937 and 76942. This PTP edit has
a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate
NCCI modifier was not billed with this PTP code edit.
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 and when necessary, the
appropriate modifiers. In this case, the claim was not billed with the required modifier. Based on this
information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we
decided that the Plan does not have to pay for hospital services provided to the enrollee and coded as 76942.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for physician services and home test
kits provided from April 23, 2020, to October 15, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. You say
that no one told you there would be copayments for physician services. The Plan denied your request. The Plan
says this cost share was charged based on the claim submitted and the Plan contract agreement. Maximus
partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct cost share criteria.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay a $30 copayment for specialist services. The Medicare billing guidelines
specifically state the provision of testing materials and equipment for home anticoagulation monitoring (code
G0249) is not billed as a durable medical equipment code. This is billed as a physician service and paid by
under the Medicare Physician Fee Schedule. That is why the services to provide you with testing materials and
equipment fall within the physician specialist services benefit category. 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 or reduce the cost
share charged for physician services and home test kits provided from April 23, 2020, to October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a CGM for the enrollee.
You asked the Plan to provide coverage for CGM device for the enrollee. The Plan denied your request. The
Plan says all of the required 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.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically when all of the required coverage criteria are met. Based on the medical
records provided, the enrollee does not meet all of the criteria listed. Therefore, we decided that the Plan does
not have to provide coverage for a CGM for the enrollee.