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

 
We decided that the Plan does not have to waive the cost sharing for the bimatoprost injection provided on 
August 26, 2022. 
 
You asked the Plan to waive the cost sharing for the injection. You say that you think that the cost sharing for 
this service is too high. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance of the total cost for Part B covered chemotherapy drugs and other Part B covered drugs. 
 
You have been asked to pay a cost share of $412.80 for the injection ($2064.02 allowed amount x .20 = 
$412.80). This item/service falls within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost sharing for the bimatoprost injection provided on August 26, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for Medicare Part B drugs. We decided that the Plan 
does not have to waive the cost sharing for a foot x-ray.  
 
You asked the Plan to waive the cost sharing for Medicare Part B drugs and a foot x-ray provided on  
October 24, 2022. You say that this should be included in your cost sharing for outpatient hospital services. 
The Plan says this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the cost sharing for Medicare Part B drugs.  
 
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 must pay 20% coinsurance for in-network Medicare Part B prescription 
drugs.  
 
For the bundled Part B drug charges (revenue code 0250) the Plan allowance was $85.42. The Plan applied a 
$17.36 coinsurance. You are only responsible to pay $17.08 ($85.42 x 20% = $17.08) 
 
For the cefazolin sodium injection, the Plan allowance was $13.05. The Plan applied a $2.65 coinsurance. You 
are only responsible to pay $2.61 ($13.05 x 20% = $2.61). 
  
For the propofol injection, the Plan allowance was $50.12. The Plan applied a $10.19 coinsurance. You are 
only responsible to pay $10.02 ($50.12 x 20% = $10.02). 
 
For the fentanyl citrate injection, the Plan allowance was $7.25 The Plan applied a $1.47 coinsurance. You are 
only responsible to pay $1.45 ($7.25 x 20% = $1.45). 
 
For the Ringers lactate infusion, the Plan allowance was $33.52. The Plan applied a $6.81 coinsurance. You 
are only responsible to pay $6.70 ($33.52 x 20% = $6.70). 
 
The Plan says you must pay a total coinsurance amount of $38.48 for Part B drugs. Based on your contract with 
the Plan, however, you cannot be asked to pay more than $37.86 coinsurance amount for Part B drugs. 
Therefore, we decided that the Plan has to reduce the cost sharing for Medicare Part B drugs from $38.48 to 
$37.86. 
 
We also decided that the Plan does not have to waive the cost sharing for a foot x-ray. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. The Plan 
contract says that you must pay a $35 copayment per day, per in-network provider, for x -ray services. 
 
Therefore, we decided that the Plan does not have to waive the cost sharing for a foot x-ray. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed for date of service 
October 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that it is impossible to continue treatment without the 
supplies. The Plan denied your request. The Plan says the billed supply code cannot be verified. 
 
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.  
 The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the electrical stimulator supplies billed for date of service October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you have bacteria in your blood stream 
and do not have long to live. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and you can get the services you need provided safely in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. You do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza injector pen. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The 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 pre-approve Victoza injector pen.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that if the enrollee is discharged to a skilled nursing 
facility, they will get little to no care and have a greater risk of not being able to return home. You say that the 
enrollee's needs therapy to be able to gain their strength back. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and the enrollee can get the services they need in other settings. 
 
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. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for laboratory services provided to the enrollee on May 22, 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. The
Plan requested a reopen and provided additional information. The Plan noted that while they agree, the
specimen may have been obtained in the hospital setting, the claim form listed the place of service (POS) as 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. If an independent laboratory bills for a test on
a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off
campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively.
The date of service for a clinical laboratory test or the technical component of physician pathology service must
be the date the specimen was collected with 3 exceptions. Maximus references the exceptions regarding a
ADLT collected from a hospital outpatient during an encounter. There is no documentation of molecular
pathology testing performed on a specimen collected during an outpatient encounter properly billed with the
date of service May 22, 2021, and the laboratory billed POS as 81.
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, the claim was
billed with a POS code of 81, indicating the specimen was taken by the billing lab. However, the medical
record shows the specimen was taken during the outpatient hospital encounter. Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory
services provided to the enrollee on May 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx prostate cancer testing provided on August
25, 2021.
You asked the Plan to pay for the testing. You say that this test was medically necessary and reasonable. The
Plan denied your request. The Plan says that there is no documentation that the sample was taken in the
laboratory.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical
necessity issue but the fact that the claim was submitted with an error. 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, however, the specimen
was not collected in an independent laboratory.
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 code. In this case, this claim
cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing
have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx prostate cancer
testing provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous hydration services provided to the enrollee on
May 7, 2020 and billed under code 96360.
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 coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria. The Plan says that
based on Medicare LCD is based on services rendered in the region.
The services were rendered in a state, therefore the guidelines for LCD L34960 were correctly
applied and this claim cannot be paid as billed.
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, code 96360
was not billed appropriately on this claim. Therefore, we decided that the Plan does not have to pay for
intravenous hydration services provided to the enrollee on May 7, 2020 and billed under code 96360.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for molecular pathology provided to the enrollee on April 13, 2022.
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. The
Plan requested a reopen and provided additional information. The Plan noted that while the Plan agrees there
are exceptions to the general rule on date of service (DOS), none of those apply based on the information
submitted by the provider. The testing was performed on peripheral blood collected on April 4, 2022, and not
on a biopsy specimen collected during a hospital encounter. The test was billed with place of service (POS) 81,
which contradicts the assertion that the specimen was obtained during a hospital outpatient encounter.
Therefore, the exceptions to the general rule for date of service would not apply in this case. Medicare rules
stated if an independent lab bills, the place where the sample was taken is shown. An independent laboratory
taking a sample in its laboratory shows "81" as place of service.
If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses
the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus out patient
hospital (POS code 22), respectively The date of service for a clinical laboratory test or the technical
component of physician pathology service must be the date the specimen was collected with 3 exceptions.
None of those exceptions apply as the provider billed POS 81 not inpatient (21) or outpatient hospital (22).
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 as billed due to issues with the POS code reported. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for molecular pathology
provided to the enrollee on April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for surgical codes 47600 and 44110 provided to the enrollee on
February 8, 2022.
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 partially overturned the Plans
denial for code 44110 and upheld the denial for code 47600. The Plan requested a reopen and provided
additional information.
The Plan noted that the medical records do not confirm code 44110-59 can be paid. The code definition states
"The physician removes one or more lesions in the small or large intestine through an incision in the colon
(colotomy) or small intestine (enterotomy) without bowel resection. The physician makes an abdominal
incision. Next, the segment of small intestine or colon containing the lesions is mobilized. An incision is made
in the small intestine or colon and the lesions are removed. The enterotomy orcolotomy is closed with staples
or sutures." The Plan notes the operative report does not describe or document an enterotomy or colotomy with
removal of lesions. To cite the operative report; "The Bookwalter retractor system was then repositioned, and
the left gutter was fully mobilized dividing adhesions to the sigmoid colon so that this was fully mobilized.
Attention was then directed to the right colon which was mobilized along the white light of "Toldt" towards the
hepatic flexure and in the appendiceal stump there was significant tumor recurrence and an extraperitoneal
approach was used in this location. The colon was then divided using a linear cutter 75 blue load just proximal
to the middle colic vessels." Based on this submission, the description was not present.
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 code. In this case, we do not find
the description for code 44110 is contained in or referenced to in the medical records provided. Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
surgical services (47600 and 44110) provided to the enrollee on February 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits for
the enrollee.
You asked the Plan to pre-approve twelve (12) additional physical therapy (PT) visits. You say that the enrollee
has had a significant decline in independence with all areas of living. The Plan denied your request. The Plan
says that these services are not covered.
Our Medical director looked at the case file and the reopen request. At issue is coverage for twelve (12)
additional physical therapy (PT) visits. Our Medical Director states that the available documentation is
insufficient to demonstrate that the unique skills of a professional therapist were required to safely and
effectively provide treatment, that the services could be safely and effectively performed only by a therapist, or
for physical therapy and occupational therapy, by or under the supervision of a therapist. Our physician
reviewer found that the enrollee's condition does not meet criteria for coverage of twelve (12) additional
physical therapy (PT) visits.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of twelve (12) additional physical therapy (PT) visits have not been met.
Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT)
visits for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Amvuttra solution. 
 
You asked the Plan to pre-approve Amvuttra. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Amvuttra solution.  
 
Benefits for Amvuttra may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's chance to return home and maintain 
living at home will be significantly reduced if the opportunity to participate in an acute rehab program is 
denied. You say the enrollee meets all applicable criteria for admission to an IRF. The Plan denied your 
request. The Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
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. 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.