Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the filling (D2160) for tooth #15 by on 
October 18, 2022. 
 
You asked the Plan to waive the coinsurance for the dental service. You say that the dental procedure should 
not be denied and should be a covered benefit. The Plan denied your request. The Plan says this cost sharing 
was charged correctly, and the enrollee is responsible for the contracted fee. 
 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 for class 2 basic services, if a method of treatment is more costly than is customarily provided, 
benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining 
balance. The amount difference between the denied filling and the approved filling was $64 ($220 denied 
filling - $156 approved filling). The total allowed amount for the approved filling was $156 with a coinsurance 
of $31.20 ($156 allowed amount x 20% coinsurance). The total amount you are responsible for is $95.20 ($64 
difference amount + $31.20 coinsurance). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
You have been asked to pay $95.20 for the dental service. This item/service falls within the Plans Dental Option 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 coinsurance for 
the filling (D2160) for tooth #15 by on October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 21, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. 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 stated that Maximus did not apply the correct criteria. The Plan notes that 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 sample was by the physician and submitted to the lab. There is no documentation that the bone marrow biopsy sample was taken by the laboratory directly.
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, along with statutory exclusion, this case could not be paid due to an issue with the POS code. Medicare coverage criteria were not met. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for epidural steroid injections (64484, 64483).
You asked the Plan to provide coverage for epidural steroid injections (64484, 64483). You say that at the time of the appeal, this treatment was medically necessary. The Plan denied your request. The Plan says the 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 criteria. The Plan noted that The Maximus reviewer did not consider that there is no documentation the enrollee has foraminal or central spinal stenosis at the levels requested to be injected. The Plan also states the Maximus reviewer did not address the pathology at L3-4 and L4-5 or that increased uptake on SPECT CT without stenosis is not included in the criteria for transforaminal epidural steroid injection. Medicare criteria clearly were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of treatment with specific documentation requirements in the medical records.
Based on the records provided, the required criteria are not met in the documentation submitted. All the required Medicare rules for coverage of this treatment were not met. Therefore, we decided that the Plan does not have to provide coverage for epidural steroid injections (64484, 64483).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 25, 2022.
You asked the Plan to pay for these services. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria. The Plan states that the record show the specimen was collected on November 5, 2019, rather than on the billed date of March 25, 2022. The claim also did not include the required unique test identifier code.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim could not be paid as billed due to issues with the dates of service reported and a lack of documentation showing the required coverage criteria were met. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 28, 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 stated that Maximus did not apply the correct criteria. The Plan notes that the clinical information provided does not support coverage under NCD 90.2. There was no documentation of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. There is also no documentation that the patient has not been previously tested with the same test using NGS for the same cancer genetic content and decided to seek further cancer treatment (e.ge., therapeutic chemotherapy). Additionally, the claim was billed with a place of service (POS-81) inconsistent with Medicare rules. An independent laboratory taking a sample in its laboratory shows "81" as place of service. There is no documentation that the specimen was taken by the laboratory directly. The specimen was collected on May 28, 2021, and not received by the laboratory until June 4, 2021, confirming that this sample was not taken by the laboratory directly.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the documentation does not support the services billed and the POS code reported was invalid. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pacemaker replacement procedure (33228) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that the enrollee is an established patient, and it is important for continuity of care that this service is provided by you. The Plan denied your request. The Plan says that the same provider has privileges at their preferred participating in network facility within the same distance.
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 pacemaker replacement procedure (33228) to be provided by an out-of-network (OON) provider.
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 at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan states Maximus did not apply the correct criteria. The Plan states at the time of the appeal the records show enrollee exhibited medically complex issues. The progress noted dated September 19, 2022, state the enrollee "should remain in the acute inpatient setting at this time."
The Plan is correct in this case. 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. Based in the medical records provided, at the time of the appeal, the enrollee did not have the ability to participate in an intensive rehabilitative therapy program. All the required Medicare criteria were not 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 4, 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 for medical necessity. The Plan requested a reopen and provided additional information. The Plan noted that 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. The claim was also billed with a date of service inconsistent with Medicare rules governing laboratory services. The laboratory records submitted show that biopsy was performed on peripheral blood which was collected on March 23, 2022. There is no documentation of molecular pathology testing performed on a specimen collected by the laboratory billable with the date of service of April 4, 2022, and POS code 81. The claim form contradicts the rationale used by Maximus to overturn the denial. The laboratory billed POS code 81 when they should have billed POS code 21, as the specimen was taken by the facility and not the independent lab.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim could not be paid due to issues with the POS code reported and the dates of service and specimen collection reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 4, 2022.
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. You say that at the time of the appeal, IRF admission was medically necessary. 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 noted the Maximus reviewer did not consider the enrollees inability to participate in intensive therapy due to a recent below the knee left leg amputation. The records show the enrollee also had weakness and fatigue. The records also show the enrollee did not require visits with a physical medicine and rehab physician at least three times a week.
The Plan is correct in this case. 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. Based on the medical records provided, at the time of the appeal, the records do not show the enrollee had the ability to or would improve from an intensive rehabilitation program. Medicare rules for coverage of IRF care have not been 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: 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. You say that at the time of the appeal, IRF admission was medically necessary for the enrollee. The Plan denied your request. The Plan says the required Medicare criteria for coverage were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan states the Maximus reviewer did not consider that this enrollee's inability to participate in intensive therapy due to limited by weakness and that it was not reasonable to expect the enrollee would be able to actively participate in or benefit significantly from the intensive rehabilitation therapy program. It was not expected that the enrollee's condition and functional status were such that she could reasonably be expected to make measurable improvement.
The Plan is correct in this case. 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.
Based on the medical records provided, the enrollee did not require nor was she reasonable expected to have the ability to actively participate in and to benefit from an intensive rehabilitation therapy program. Medicare rules for coverage of IRF care have not been 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for IRF admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the corrected criteria. The Plan noted that Maximus approved transfer to an IRF facility from an LTACH because "the enrollee has multiple medical complications that require close monitoring on an inpatient basis." The Maximus reviewer did not consider that enrollee was not able to participate in intensive therapy was severely limited by weakness and pain. At the time of the appeal the enrollee did not require physician supervision by a rehabilitation physician at least 3 days per week for these issues, especially following a two month stay in an LTACH.
The Plan is correct in this case. 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.
Based on the medical records provided, the enrollee was not of a physical condition to have the ability to participate in an intensive rehabilitative therapy program. Medicare rules for coverage of IRF care have not been 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal IRF admission was medically necessary. 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 criteria. The Plan notes that the Maximus reviewer did not consider you had several medical issues including malnutrition and infection. You did not require physician supervision by a rehabilitation physician at least 3 days per week or an interdisciplinary team. You were not expected to or demonstrated the ability to participate in intensive therapy. It was noted that due to weakness and fatigue noted you were not successful with short sessions of therapy while in the hospital.
The Plan is correct in this case. 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.
Based on the records provided, you did not meet all the required Medicare that would allow coverage for IRF admission. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 7, 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 billing information. The Plan notes that this is an administrative determination for billing and is not based on clinical criteria for medical necessity. 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. The specimen was collected during a hospital outpatient encounter. Therefore, POS code 81 would not apply. Further, per the Medicare Local Coverage Article (A53628) in effect on the date of service, testing for the FANCC gene is not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene is statutorily excluded service. The FoundationOne CDx (F1CDX) panel includes testing for FANCC.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim could not be paid due to issues with the POS code reported and the rules in place at the time the service was provided. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an OsteoCel allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for lumbar 
spondylolisthesis. She presented with lumbar pain that is longstanding and has progressively worsened over the 
years. There is radiation of the pain to the bilateral buttocks and legs. The exam reveals no signs of muscle 
atrophy. Strength and sensation are intact. There is limited published, large-scale, long-term peer-reviewed 
literature that shows Osteocel allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested OsteoCel allograft, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an OsteoCel allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration (20939) for a spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large-volume, long-term, peer-reviewed outcome studies to 
support the use of bone marrow aspirate for your medical condition. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration (20939) for a spinal surgery.