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

 
We decided that the Plan does not have to pre-approve a diagnostic computed tomography of the thorax 
(71250) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a diagnostic computed tomography of the thorax. You say that you believe 
that this should be covered as the hospital that is near to you, you have been to and feel that you did not make 
any progress. You also say that you are seeing a provider and the requested hospital is the hospital where he 
practices. The Plan denied your request. The Plan says an out-of-network computed tomography (CT) scan of 
the chest is not medically necessary at this time because the requested service is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a diagnostic computed tomography of the thorax (71250) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for Medicare Part B drugs provided on
May 18, 2021.
You asked the Plan to waive this cost share. You say that no one told you there would be a cost share. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the Plan
contract agreement. Maximus administratively overturned the Plans denial for insufficient information in the
case file. The Plan requested a reopen and provided additional information regarding its denial.
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 20% coinsurance for Medicare Part B drugs and administration.
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 charged for Medicare Part B drugs provided on May 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Nivestym for the enrollee.
You asked the Plan to provide coverage for Nivestym. You say that this drug should be covered by the Plan.
The Plan denied your request. The Plan says this drug would be covered under the clinical trial the enrollee is
part of. Maximus overturned the Plans denial stating the symptoms were not related to the clinical trial
treatment. The Plan requested a reopen and provided additional information. The Plan stated Medicare covers
the routine costs of qualifying clinical trials. The enrollee is receiving the experimental drug (CFT7455 - an
orally bioavailable MonoDAC (monofunctional degradation activating compound) targeting IKZF1/3). The
medical records clearly indicate that the enrollee has agranulocytosis secondary to cancer chemotherapy,
therefore coverage of Nivestym (filgrastim-aafi) would be deemed a routine cost covered by the Medicare
contractor.
The Plan is correct in this case. Based on the medical records and the treatment being receive, coverage for this
drug should be submitted to the Medicare contract for the clinical trial. Therefore, we decided that the Plan
does not have to provide coverage for Nivestym for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services
(code 84443) provided to the enrollee on July 26, 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 this test was ordered for a screening and is not covered by Medicare.
Maximus overturned the Plans denial stating this "screening" was medically appropriate. The Plan requested a
reopen and stated that screenings of this type may be necessary but are not covered by Medicare.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests,
with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this
appeal, these services, was requested solely for screening purposes. Medicare does not cover this test solely for
screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory services
(code 84443) provided to the enrollee on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no evidence of a new or recent compression fracture. 
 
The Plan must follow Medicare rules. Medicare rules say that PVA may be covered if the Medicare criteria 
have been 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 requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of an acute fracture. Imaging studies do not show a new fracture. Our physician reviewer found 
that your condition does not meet criteria for coverage of PVA. 
 
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 percutaneous vertebral augmentation (PVA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network consultation services.
You asked the Plan to provide coverage for out of network providers. You say that you prefer to see the
requested provider. The Plan denied your request. The Plan says the contract is clear that enrollees must use
network providers. Maximus overturned the Plans denial because an Evidence of Coverage or plan contract
was not submitted with the case file. The Plan requested a reopen and submitted the required contract.
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 provide coverage 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. Therefore, we decided that the Plan does not have to provide
coverage for out of network consultation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on August 26, 2021 to August 31, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
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 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 inpatient care provided on August 26, 2021 to August 31, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for facet joint injections.
You asked the Plan to provide coverage for facet joint injections. The Plan denied your request. The Plan says
Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for facet joint
injections. The Maximus Physician Reviewer determined the request was medically reasonable. The Plan
requested a reopen. The Plan stated it was confirmed the physician had not ordered the pain injections and was
not going to order them until you were seen by their practice. The Plan states as of the reopen request you had
not followed up with the specialist and the office had not ordered the pain injections for you.
The Plan is correct in this case. There is insufficient clinical documentation in the case file to support that facet
joint injections are medically reasonable and necessary and that they were properly ordered by your physician.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to provide coverage for facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imlygic for the enrollee. 
 
You asked the Plan to pre-approve Imlygic. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this use is not supported by the FDA and/or nationally recognized compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Imlygic. Our reviewer says that Imlygic 
is not medically reasonable and necessary. Imlygic is not FDA-approved for the enrollees diagnosis. The use 
of Imlygic is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of Imlygic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imlygic have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imlygic for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gynecology services provided on October 13, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the gynecology services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the gynecology services provided on October 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) angiography 
of the chest provided on November 19, 2021. 
 
You asked the Plan to reduce the copayment for a CT angiography scan. You say that you cannot afford the 
cost share. You also say you were unaware that it would have been cheaper at an independent diagnostic testing 
facility or specialist's office. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $225 
copayment for advanced imaging services, including CT scans at an outpatient hospital facility.  
 The record shows the CT scan you had on November 19, 2021, was done at an outpatient hospital facility. You 
have been asked to pay a $225 copayment for a CT angiography scan. A CT angigraphy scan falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 reduce the copayment for a computed tomography (CT) angiography of the chest provided on November 19, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement, socket, below knee (BK) (L5700), 
addition to lower extremity, test socket (L5620), additions to lower extremity, below knee (L5629, L5637, 
L5645, L5668, L5671, L5673), and an addition, endoskeletal system, below knee (BK) (L5940) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a replacement, socket, below knee (BK), addition to lower extremity, test 
socket, additions to lower extremity, below knee, and an addition, endoskeletal system, below knee (BK). You 
say that the member's present socket is no longer fitting well, and the socket is uncomfortable and creating 
pressure areas on his residual limb. The Plan denied your request. The Plan says the member's records received 
do not indicate that he has an emergent or urgent medical condition, or in need of specialized service, and there 
are in-network providers within a reasonable distance from his location that can provide this service or item. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a replacement, socket, below knee (BK) (L5700), addition to lower extremity, test socket (L5620), additions to 
lower extremity, below knee (L5629, L5637, L5645, L5668, L5671, L5673), and an addition, endoskeletal 
system, below knee (BK) (L5940) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823, K0108, E2365, E2366). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the powerchair is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested power wheelchair is not medically necessary. Our physician reviewer found the 
documentation doesn't support that the member requires a power mobility device to accomplish mobility-
related self-care tasks. Additionally, the documentation doesn't support that she is unable to use a manual wheelchair or a walker. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0823, K0108, E2365, E2366).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's medical and therapy needs could be met in a skilled 
nursing unit. 
 
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. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for diarrhea, falls, 
Clostridium difficile infection, and urinary tract infection. The enrollees medical problems are stable. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 the enrollee does not have documented skilled 
nursing needs. The enrollees wound care needs are every other day. The enrollee does not have documented 
skilled therapy needs. The enrollee is mobilizing with supervision. The enrollees care needs, custodial and 
intermittent, can, as a practical matter, can be provided at a lower level of care. 
 
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 that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you want to go to the out-of-network 
provider because it is closer. The Plan denied your request. The Plan says an in-network provider that provides 
the same quality service was given to the enrollee that is within 5 miles from the enrollee's residence. 
 
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 
chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) facility. 
 
You asked the Plan to pre-approve cataract surgery. You say that the cataract surgery is necessary. The Plan 
denied your request. The Plan says the services have been requested from an out-of-network facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers and facilities. 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 facility in this case is not in-network with the Plan. The Plan has network facilities 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 cataract surgery 
to be provided by an out-of-network (OON) facility.