Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services, medical examination provided by on January 14, 2021, and February 19, 2021.

You asked the Plan to pay for ophthalmological services, medical examination. The Plan denied your request. The Plan says the provider is out-out-network and the services provided were not preauthorized.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services, medical examination provided on January 14, 2021, and February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors.

You asked the Plan to pre-approve Freestyle Libre sensors. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for continuous glucose monitors and related supplies have not been met.

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. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve out of network open magnetic resonance imaging.
You asked the Plan to pre-approve out of network open magnetic resonance imaging. You say that you prefer the requested provider. The Plan denied your request. The Plan says the records do not show out of network services are required. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the medical records do not clearly show a health condition that requires an open imaging session.
The Plan is correct in this case. 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 in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve out of network open magnetic resonance imaging.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for low frequency, non-contact, non-thermal
ultrasound, including topical application(s) (Current Procedural Terminology (CPT) code 97610).
You asked the Plan to provide coverage for these services. At the time of the appeal, you stated this treatment
was required due to an ulcer on the foot. The Plan denied your request. The Plan says at the time of the appeal
Medicare coverage criteria were not met. Maximus overturned the Plans denial due to the case file lacking
medical records. The Plan requested a reopen and provided the required medical records.
Based on the Medicare rules and the medical records provided, the Plan is correct in this case. The Plan must
follow Medicare rules. Medicare rules state the documentation must specifically show the wound in question
was deemed non-healing despite previous therapies. The medical records do not show a failed response to prior
wound care measures. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not
have to pre-approve low frequency, non-contact, non-thermal ultrasound, including topical application(s),
(Current Procedural Terminology (CPT) code 97610).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the pelvis (72192) provided on September 23, 2021.
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare coding regulations.
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, we have confirmed that code 72192 is a column II code to column I code 74177. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the pelvis (72192) provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies provided from November 17, 2019, through December 16, 2019.
You asked the Plan to pay for the infusion supplies. You say that you would like this claim reprocessed based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a valid Proof of Delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. We looked at the file and Medicare rules. The record does not contain a valid proof of delivery for the supplies provided in this case.
Specifically, the documentation does not note the actual date that the supplies were delivered and does not include an enrollee signature. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Based on this information, we decided that Medicare rules for coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies provided from November 17, 2019, through December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do not meet the criteria.

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 does not indicate that you perform blood glucose testing at least four times per day, 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. At the time of the appeal, you stated IRF services were
medically necessary. The Plan denied your request. The Plan stated Medicare coverage criteria for IRF
services were not met. Maximus administratively overturned the Plans denial due to a lack of medical records
in the file. The Plan requested a reopen and provided the required medical records.
Based on the medical records provided, the Plans denial was correct. The Plan must follow Medicare rules. The
rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the
Medicare rules section. The documentation provided did not demonstrate that at the time of the appeal, the
enrollee required an intensive multidisciplinary rehabilitation program. There were no specific medical or
functional circumstances which warranted IRF admission. It was recommended in the notes that the enrollee
could be treated in a skilled nursing facility, however this was noted to be refused by the family.
We note that the previous overturn was done administratively as medical records were not submitted for
review. Based on the medical records now presented and specific the notes from those treating the enrollee at
the time of the appeal, Medicare coverage criteria for IRF admission were not met. Therefore, we decided that
the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and
services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the influenza virus vaccine (90686), and the vaccine administration (G0008) rendered by the out-of-network (OON) provider on November 19, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the influenza virus vaccine (90686), and the vaccine administration (G0008) rendered by the out-of-network (OON) provider on November 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a LifeVest (K0606) provided from July 23, 2021, to August 23, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a LifeVest. You say that due to the processes of the Plan, this provider could not reasonably have known a prior authorization was required or secured a prior authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were they approved in advanced.

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 LifeVest (K0606) provided from July 23, 2021, to August 23, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser ablation of the prostate provided on June 10, 2021.
You asked the Plan to pay for the laser ablation of the prostate. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the services performed were not medically reasonable and 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 the laser ablation of the prostate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the evidence of the ablation services is highly heterogeneous and inconsistently reports clinical outcomes. No prospective, comparative evidence was found for the majority of focal laser ablation techniques versus current standard treatment of localized prostate cancer, including radical prostatectomy, external-beam radiotherapy, or active surveillance. Methods have not been standardized to determine which and how many identified cancerous lesions should be treated for best outcomes. Although high disease-specific survival rates have been reported, the short follow-up periods and small sample sizes preclude conclusions on the effect of any of these techniques on overall survival rates.
The adverse event rates associated with focal laser ablation appear to be superior to those associated with radical treatments (e.g., radical prostatectomy, external-beam radiotherapy); however, the evidence is limited in its quality, reporting, and scope. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The procedure cannot be covered according to Medicare rules. 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 laser ablation of the prostate have not been met. Therefore, we decided that the Plan does not have to pay for the laser ablation of the prostate provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walk-in tub (99070), provided on July 22, 2021.
You asked the Plan to pay for a walk-in tub. You say that the item is medically necessary. The Plan denied your request. The Plan says this item does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for a walk-in tub (99070), provided on July 22, 2021.
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 requested admission to a SNF is medically
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the
enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chemotherapy regimen of Alimta (Pemetrexed),
Carboplatin and Keytruda (Pembrolizumab).
You asked the Plan to pre-approve this drug regimen. You say that this drug treatment 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 for a chemotherapy
regimen of Alimta (Pemetrexed), Carboplatin and Keytruda (Pembrolizumab). The Maxims Physician
Reviewer determined that the combination of carboplatin/pemetrexed with pembrolizumab is FDA approved
for the treatment of the lung as first-line therapy in patients without a driver mutation. Our physician reviewer
found that while no PD-L1 is provided, a liquid biopsy was done and there was no EGFR or ALK mutation that
were actionable. The service is reasonable and medically necessary.
The Plan requested a reopen and noted that a July 2021 Guardant 360 test showed EGFR amplification. The
Plan states based on the clinical submitted, medical compendia, and NCCN guidelines, the use of Keytruda
with EGFR positive status is not current accepted clinical practice outside of a clinical trial.
All actionable molecular markers must be negative per NCCN guidelines. The medical records show the
enrollee is a 67-year-old woman with stage IV non-small cell lung cancer, with multiple metastases to bone.
EGFR Amplification was detected Low (+). KRAS Activating SNVs also detected (KRAS G12D).
Our Medical Director has concluded that the Plan is correct in this case. The documentation which includes
genetic testing does not support that a regimen of Alimta (Pemetrexed), Carboplatin and Keytruda
(Pembrolizumab) was medically reasonable and necessary for the enrollee in this case and was reasonably
expected to be safe and effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this drug regimen have not been met. Therefore, we decided that the Plan does
not have to pre-approve a chemotherapy regimen of Alimta (Pemetrexed), Carboplatin and Keytruda
(Pembrolizumab).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost share for the outpatient hospital services provided on August 10, 2021, and August 27, 2021.
You asked the Plan to reduce the cost share for the outpatient hospital services. You say that The Plan denied your request. The Plan says that the correct cost share has applied.
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 $350 copayment for Outpatient surgery and Other Medical Services Provided at Hospital Outpatient Facilities. The contract does not say that you should expect to pay a $350 copayment PER EACH service you receive in an outpatient hospital facility setting. Per the Plan's contract, you should not be charged for more than your $350 copayment for each date of service. Therefore, we decided that the Plan has to reduce the cost share for the outpatient hospital services provided on August 10, 2021, and August 27, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of a spinal cord stimulator (63688, 6661) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the removal of a spinal cord stimulator. You say that this must be performed by the same surgeon that put it in. The Plan denied your request. The Plan says there are in-network providers available to perform this service.
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 the removal of a spinal cord stimulator (63688, 6661) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on September 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that you depend on the hospital staff to verify eligibility and to obtain prior authorization. You say the doctor should not be penalized, and the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on September 28, 2021, by an out-of-network (OON) provider.