Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair electronic connection (E2310). 
 
You asked the Plan to pre-approve a power wheelchair electronic connection. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this 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 a power wheelchair electronic 
connection. Our reviewer says that the requested item is not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have adequate upper extremity strength to operate the wheelchair's 
power options with their own switches.  
 
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 power wheelchair electronic connection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair electronic connection (E2310).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Intraosseous nerve ablation procedure 
(64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are writing to request prior 
authorization for intraosseous ablation of the basivertebral nerve (BVN) which is accomplished with the 
Intracept procedure. The Plan denied your request. The Plan says this type of treatment is considered 
experimental /investigational. There is not enough evidence to show that it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept Intraosseous nerve ablation procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
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 a manual wheelchair is 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 documentation does not support 
that the enrollee has a mobility limitation that significantly impairs the ability to participate in one or more 
mobility-related activities of daily living (MRADLs). The documentation does not support that he has a 
mobility limitation that cannot be sufficiently resolved by the use of an appropriately-fitted walker or that his 
home provides adequate access between rooms, maneuvering space, and surfaces for the use of the manual 
wheelchair. The documentation does not support that the use of the manual wheelchair will significantly 
improve the enrollee's ability to participate in MRADLs in the home. The manual wheelchair is not reasonable 
or medically necessary at this time. 
 
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 manual wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation without medical services 
provided on August 30, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation without medical services. You say that have 
seen this provider under the Plan previously and you would like to continue medical treatment with this 
provider as you would not feel comfortable with a new provider. The Plan denied your request. The Plan says 
the provider is not eligible to bill Medicare because provider is a licensed professional counselor (L.P.C). A 
L.P.C is not eligible to bill Medicare for mental health services. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation 
without medical services provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xF genetic testing services provided to the enrollee on November 9, 2021.
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says that the testing that was ordered is supported only for the treatment of non-small cell lung cancer.
Our Medical director looked at the case file and the reopen request. At issue is coverage for Tempus xF genetic testing services. Our Medical Director states that the documentation does not support that the coverage criteria for the Tempus xF Panel genetic testing in this case met the coverage criteria for genetic testing. This testing does not have FDA approval or clearance, and an FDA-approved or FDA-cleared indication for use in this enrollee's cancer. In addition, there is insufficient evidence in the medical literature to support the clinical utility of Tempus xF Panel testing in this setting. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF genetic testing services provided to the enrollee on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (0037U) billed for date of service March 14, 2022.
You asked the Plan to pay for the genetic testing. You say that the genetic testing was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because the genetic testing was billed with the incorrect date of service.
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the specimen was collected. We looked at the file and Medicare rules. The file indicates that the DOS of the test is not the same as the date the specimen was collected. 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 the genetic testing (0037U) billed for date of service March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on November 29, 2021.  
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee is treated for spinal 
degenerative disc disease and chronic pain with opioids and gabapentin. The submitted documentation does not 
show evidence of an unexpected result from urine drug screening at the point of care to justify follow up 
definitive drug testing, particularly for more than four medication classes, as the other classes were not 
pertinent to the enrollee's case. There is no indication of drug abuse or misuse or other indication for the 
definitive testing. The testing 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing rendered on November 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided the Plan has to pay for out of network methadone treatment and counseling services provided from December 6, 2021, to December 27, 2021.
You asked the Plan to pay for this treatment. You stated that the enrollee was referred for this treatment by his physician. You stated this is a daily dosing and counseling program for Methadone treatment and you are currently the only provider in the enrollee's area who provides the type of treatment program the enrollee is part of. The Plan denied your request. The Plan says these services can be provided in network and the enrollee has been redirected to a provider in network. Maximus dismissed the case in error. The Plan requested a reopen and a full review was performed. In the midst of the review, Maximus asked the Plan for additional information regarding when the enrollee began methadone treatment and who ordered the treatment. Maximus also asked for a list of providers within a reasonable driving distance of the enrollee's home that could provide treatment. Once this information was submitted the appeal went to medical review.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for methadone maintenance treatment. The enrollee has been enrolled in an Opioid Treatment Program (OTP) since March 2020 and began with your facility in January 2021. The medical records show the enrollee is a 66-year-old man with diagnoses of Opioid Dependence Uncomplicated, and other problems related to lifestyle. The enrollee has been receiving out of network maintenance methadone daily for chronic pain.
The Plan referred the enrollee to an in-network provider. A map review shows that this office is 32.5 miles away from the enrollee's residence. The additional list of providers shows no closer alternatives are identified. If the enrollee is to travel to the addiction program office daily to receive the needed medication, a 65 plus mile round trip daily is not reasonable.
The rules say that plans must ensure continuity of care for enrollees. We looked at this physician's review, the file, the Medicare rules and the additional information submitted by the Plan. We also referenced Google Maps and MapQuest when checking the list of providers submitted by the Plan that were stated to be able to treat the enrollee. Based on this information, we decided that Medicare rules for coverage the requested treatment have been met. Therefore, we decided that the Plan has to provide coverage for out of network methadone treatment and counseling services provided to the enrollee from December 6, 2021, to December 27, 2021.
Appeal type: Drugs
Decision: Favorable

We decided the Plan must pay for out of network methadone treatment and counseling services provided from January 3, 2022, to May 30, 2022.
You asked the Plan to pay for this treatment. You stated that the enrollee was referred for this treatment by his physician. You stated this is a daily dosing and counseling program for Methadone treatment and you are currently the only provider in the enrollee's area who provides the type of treatment program the enrollee is part of. The Plan denied your request. The Plan says these services can be provided in network and the enrollee has been redirected to a provider in network. Maximus upheld the Plans decision. After the Plan requested a reopen on another case for this enrollee, Maximus was required to review all of the cases regarding this service. During the review, Maximus asked the Plan for additional information regarding when the enrollee began methadone treatment and who ordered the treatment. Maximus also asked for a list of providers within a reasonable driving distance of the enrollee's home that could provide treatment. Once this information was submitted the appeal went to medical review.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for methadone maintenance treatment. The enrollee has been enrolled in an Opioid Treatment Program (OTP) since March 2020 and began with your facility in January 2021. The medical records show the enrollee is a 66-year-old man with diagnoses of Opioid Dependence Uncomplicated, and other problems related to lifestyle. The enrollee has been receiving out of network maintenance methadone daily for chronic pain.
The Plan referred the enrollee to an in-network provider. A map review shows that this office is 32.5 miles away from the enrollee's residence. The additional list of providers shows no closer alternatives are identified. If the enrollee is to travel to the addiction program office daily to receive the needed medication, a 65 plus mile round trip daily is not reasonable.
The rules say that plans must ensure continuity of care for enrollees. We looked at this physician's review, the file, the Medicare rules, and the additional information submitted by the Plan. We also referenced Google Maps and MapQuest when checking the list of providers submitted by the Plan that were stated to be able to treat the enrollee. Based on this information, we decided that Medicare rules for coverage the requested treatment have been met. Therefore, we decided that the Plan must pay for out of network methadone treatment and counseling services provided to the enrollee from January 3, 2022, to May 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

We decided the Plan must pay for out of network methadone treatment and counseling services provided from October 4, 2021 to October 25, 2021.
You asked the Plan to pay for this treatment. You stated that the enrollee was referred for this treatment by his physician. You stated this is a daily dosing and counseling program for Methadone treatment and you are currently the only provider in the enrollee's area who provides the type of treatment program the enrollee is part of. The Plan denied your request. The Plan says these services can be provided in network and the enrollee has been redirected to a provider in network. Maximus upheld the Plans decision. After the Plan requested a reopen on another case for this enrollee, Maximus was required to review all the cases regarding this service. During the review, Maximus asked the Plan for additional information regarding when the enrollee began methadone treatment and who ordered the treatment. Maximus also asked for a list of providers within a reasonable driving distance of the enrollee's home that could provide treatment. Once this information was submitted the appeal went to medical review.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for methadone maintenance treatment. The enrollee has been enrolled in an Opioid Treatment Program (OTP) since March 2020 and began with your facility in January 2021. The medical records show the enrollee is a 66-year-old man with diagnoses of Opioid Dependence Uncomplicated, and other problems related to lifestyle. The enrollee has been receiving out of network maintenance methadone daily for chronic pain.
The Plan referred the enrollee to an in-network provider. A map review shows that this office is 32.5 miles away from the enrollee's residence. The additional list of providers shows no closer alternatives are identified. If the enrollee is to travel to the addiction program office daily to receive the needed medication, a 65 plus mile round trip daily is not reasonable.
The rules say that plans must ensure continuity of care for enrollees. We looked at this physician's review, the file, the Medicare rules, and the additional information submitted by the Plan. We also referenced Google Maps and MapQuest when checking the list of providers submitted by the Plan that were stated to be able to treat the enrollee. Based on this information, we decided that Medicare rules for coverage the requested treatment have been met. Therefore, we decided that the Plan must provide coverage for out of network methadone treatment and counseling services provided to the enrollee from October 4, 2021, to October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 22, 2022. 
 
You asked the Plan to pay for the dental service. You say that you only received a dental evaluation on 
September 22, 2022. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on September 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 there is no documentation that you require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not support services in the long-term care facility on a part time 
basis are not appropriate in this case. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92928 billed for date of service May 16, 
2022. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation did not include this service being performed on the date of service. 
 
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 92928 is not supported in the medical record. Specifically, medical records were not 
submitted for the date of service at issue. The file shows that the Plan made multiple attempts to obtain 
additional information without success. 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 procedure 
code 92928 billed for date of service May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on February 15, 2022.
You asked the Plan to pay for these services. You say that this testing 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 for medical necessity. The Plan requested a reopen and stated the issue was not medical necessity for issues with errors on the claim. The Plan notes that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records submitted show that specimens were collected on January 18, 2022. The specimen was received on February 7, 2022. There is no documentation of molecular pathology testing performed on the date billed of February 15, 2022. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. There is no documentation that the sample was taken in the laboratory. The difference in date of collection and date received confirms that the was not collected directly by the laboratory. Additionally, the claim was billed without the required unique test identifier code or DEX Z Code.
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, this claim could not be paid due to inconsistencies with the dates of service reported and the omission of the required test identifiers. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 15, 2022.