Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara (J3358) and the administration (96365).
You asked the Plan to pre-approve Stelara and the administration. You say that Stelara is recommended to treat both the enrollee's biologic therapy induced inflammatory bowel disease and his psoriasis. The Plan denied your request. The Plan says the enrollee does not have any stated contraindications to the preferred products, nor have they tried any of them. The Plan also says that no rationale is provided for the use of non-preferred products regarding safety or efficacy.
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 Stelara and the administration. Our reviewer says that Stelara is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug(s), Remicade, Avsola or Entyvio. Our reviewer also found that although Entyvio has no reported indication for treatment of the patient's psoriasis, there is no indication that Remicade or Avsola would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Stelara and the administration have not been met. Therefore, we decided that the Plan does not have to pre-approve Stelara (J3358) and the administration (96365).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for prior authorization request for code 37766
bilateral stab phlebectomy and code 36475 bilateral endovenous ablation therapy.
You asked the Plan to provide coverage for these services. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the
Plans denial. The Plan requested a reopen and stated that we did not apply the correct coverage criteria.
The Plan says that your office submitted an appeal regarding the denial of a prior authorization request for
bilateral stab phlebectomy and bilateral endovenous ablation therapy.
The Plan states that the Medicare LCD for this service is very clear that, both endovenous ablation and stab
phlebectomy are not covered by Medicare for patients with severe distal arterial occlusive disease, which the
records show the enrollee has. The Enrollee has a severely reduced ankle/brachial pressure index on the left, a
moderately reduced ankle/brachial pressure index on the right, and a severely reduced digital/brachial index
pressure bilaterally, which is consistent with bilateral severe peripheral artery disease. In addition,
treatment of the bilateral tributary veins is not medically necessary as the enrollee has tributary veins
on the right that are less than 4 millimeters in diameter and has bilateral greater saphenous vein reflux.
Thus, treatment of the bilateral tributary vein would not be covered.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this type of treatment. The previous medical review does not apply as the LCD clearly states the services
requested in the prior authorization are not covered. Therefore, we decided that the Plan does not have to
provide coverage for code 37766 bilateral stab phlebectomy and code 36475 bilateral endovenous ablation
therapy.
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 the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 daily
skilled services are not necessary. Our physician reviewer found although further rehabilitation services would
be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a
lower level of care than a skilled nursing facility.
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: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided on March 30, 2021, to April 9, 2021,
under the Medicare benefit.
You asked the Plan for these services. You say that you do not believe this bill is correct. The Plan denied your
request. The Plan says these services must be addressed under your Medicaid benefit. Maximus overturned the
Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim
denied under your Medicare benefit because you are Medicaid eligible. The Plan included documentation to
show that you are Medicaid eligible. The Plan says that Medicare pays covered dually eligible beneficiaries'
medical services first, because Medicaid is generally the payer of last resort. Medicaid may cover medical costs
that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and
community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both.
The services provided fall under your Medicaid coverage and not your Medicare coverage. The IRE does not
have jurisdiction over your Medicaid benefits. Therefore, we decided the Plan does not have to pay for
physician services provided from March 30, 2021, to April 9, 2021n under the Medicare benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for physician services provided from
January 5, 2021, to April 5, 2021.
You asked the Plan to waive this cost share. You say that You asked the Plan to waive this cost share. You say
that you do not believe this cost share is correct. The Plan denied your request. The Plan says The Plan denied
your request. The Plan says this cost share was applied based on your dual eligibility. We overturned the
Plans denial. The Plan requested a reopen and stated this claim was processed towards your Medicaid
coverage. The Plan provided documentation to show that you are Medicaid Eligible and that this claim was
submitted to Medicaid for payment. Any concerns regarding the cost share must be addressed through
Medicaid.
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. Your contract with the Plan clearly says you are a dual eligible member. This claim
was submitted to and processed under your Medicaid benefit. Neither the Plan nor us have the authority
to waive this cost share as we can only review those services applied to your Medicare benefit. Therefore, we
decided that the Plan does not have to waive the cost share charged for physician services provided from
January 5, 2021, to April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on April 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 information. The Plan says that this claim denied because the
provider billed an inappropriate modifier. The Plan states the claim image shows the provider billed modifier
QZ which shows CRNA service: without medical direction by a physician. We found that the provider needed
to bill this service with modifier QK: Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving
qualified individuals. This modifier limits payment to 50% of the amount that would have been allowed if
personally performed by an anesthesiologist or non-supervised CRNA.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services with the appropriate code and when necessary, the appropriate modifier. In this case, this claim
cannot be paid as billed due to the omission of the appropriate modifier for the services billed. 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 on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Cyclophosphamide (J8530) provided to the enrollee from
July 14, 2020, to September 9, 2020.
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. We overturned the Plans denial for
insufficient information submitted in the case file regarding this claim. The Plan requested a reopen and
provided additional information. The Plan states that this claim for denied because it is inappropriate for a
provider with a durable medical equipment (DME) or pharmacy specialty to report immunosuppressive drugs
without the KX modifier. This modifier is used indicate that the supplier has ensured coverage criteria for the
billed items are met and that documentation to support the claim exists. The Plan states that as of April 2021,
this policy has been updated by changing the denial reason of immunosuppressive drugs that are inappropriate
to be reported without modifier KX when the provider's specialty is DME, or pharmacy based on the CMS
Immunosuppressive Drugs Local Coverage Article (A52474).
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
required modifiers. In this case, this claim cannot be paid as billed due to the omission of the required modifier
and the documentation to support the services billed. Medicare rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pay for Cyclophosphamide (J8530) provided to
the enrollee from July 14, 2020, to September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of the dental services provided.
You asked the Plan to pay for out of network dental services. You say that these dental services should be
covered by the Plan. The Plan denied your request. The Plan says out of network dental services are not
covered. Maximus upheld the Plans denial of the services provided in 2020 but overturned the services for
2021 as the Plan did not provide a copy of the 2021 dental contract. The Plan requested a reopen and provided
the 2021 dental contract for review.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan
offers a dental benefit more than Medicare coverage, the contract is clear that you must use network providers.
Therefore, we decided that the Plan does not have to pay for any of the dental services provided on July 27,
2020, and January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee on
December 29, 2020 and billed under code G0162.
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. We overturned the Plans denial stating the
records show skilled services were provided. The Plan requested a reopen and provided additional information.
The Plan states that this claim denied because the provider is a physician who has billed this service
inappropriately. The definition of code G0162 states these are services billed by a registered nurse (RN) for
management and evaluation of the plan of care; each 15 minutes. This code is not payable when billed by a
physician and not a registered nurse (RN). The case file includes the appealed claim that shows the billing
providers credentials.
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 a physician is
using a code that is reserved for registered nurses. Medicare uses a different code for physicians who provide
this type of service. Medicare rules for coverage of these services have not been met. Therefore, we decided
that the Plan does not have to pay for skilled nursing facility services provided to the enrollee on December 29,
2020, and billed under code G0162.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for renal disease treatment provided to the enrollee from January
3, 2021, to January 29, 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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for a
lack of claim information. The Plan requested a reopen and provided additional claim information. The Plan
states that this claim denied because the provider has billed inappropriately for these services.
The Plan states that the provider did not bill this service with the required route of administration modifiers JA,
JB, or JE, which is found in the Medicare Claims Processing Manual Chapter 8 for Outpatient ESRD Hospital,
Independent Facility, and Physician/Supplier Claims, Section 50.9.
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 required the
appropriate modifiers. In this case, this claim cannot be paid as billed due to the omission of the required
modifiers. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for renal disease treatment provided to the enrollee from January 3, 2021, to January 29,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided during an inpatient stay
from March 29, 2021, to March 31, 2021, under the Medicare Part B benefit.
You asked the Plan to pay for self-administered drugs provided during an inpatient stay under Medicare Part B.
You say that this bill should be covered by the Plan. The Plan denied your request. The Plan says the Plan
contract is clear that self-administered drugs provided during an inpatient stay would need to be submitted to
your Part D carrier. We overturned the Plans denial stating these charges should have been covered under
the inpatient claim payment. The Plan requested a reopen and stated we did not apply the correct
contract or Medicare language.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare Part B
generally does not pay for self-administered drugs. This includes self-administered drugs provided during a
facility stay. The payment for self-administered drugs requested here are not among the types which are
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered
drugs provided during an inpatient stay from March 29, 2021, to March 31, 2021, under the Medicare Part B
benefit. These charges should be submitted to your Medicare Part D carrier at the time of service for review.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 8, 2022.  You asked the Plan to pre-approve the continued SNF care. You say that the records should support that continued SNF care is necessary. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for continued SNF level of care.  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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was admitted to the hospital after a stroke. She was discharged to the SNF for weakness and dysphagia on 12/15/2021. The most recent therapy documentation indicates the member continues to be dependent for self-care tasks and mobility. She is also receiving nutrition via a feeding tube without complications.   At the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of 1/8/22, the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 1/8/22.  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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 8, 2022.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 daily skilled services are not necessary. Our physician reviewer found there are no services offered at a SNF that are not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation services is 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve SNF care to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 provider at issue in this case is not a network provider with the Plan. 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 to be provided by an OON provider. Our reviewer says that the services are not medically necessary. Our physician reviewer found the plan indicated that SNF services are available for the enrollee in network.
There are no extenuating factors that would require this enrollee to go to an out of network SNF. He could benefit from additional skilled therapy for continued work on endurance and to reduce his fall risk and safe transfers but therefore are not extenuating factors why the SNF recommended by the plan would not provide safe and effective skilled 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 SNF care to be provided by an OON provider have not been met. 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 SNF care to be provided by an OON provider. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.