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

 
We decided that the Plan does not have to pre-approve a service dog (S5199). 
 
You asked the Plan to pre-approve a service dog. You say that you are in full support of the enrollee obtaining 
an emotional support dog, as they would undoubtedly benefit from it tremendously. The Plan denied your 
request. The Plan says it was unable to be verified that the enrollee owns a service dog that meets the use and 
criteria for a service dog as defined under the Americans with Disabilities Act (ADA). The Plan also says the 
enrollee confirmed the dog is used for emotional support and not as a service dog. 
 
The Plan must follow Medicare rules. Medicare rules say that a Medicare Advantage (MA) plan may offer 
coverage of a supplemental benefit only if it is medically necessary and additional to the benefit covered by 
original Medicare. 
 
 
  We looked at the file and Medicare rules. The Plan is using the ADA definition of a service dog that is 
individually trained to do work or perform tasks for people with disabilities. The work or task a service dog has 
been trained to provide must be directly related to the persons disability. Dogs whose sole function is to 
provide comfort or emotional support do not qualify as service animals under the ADA. For more information, 
refer to the Americans with Disabilities Act (ADA). Based on this information, we decided that Medicare rules 
for coverage of a service dog have not been met. Therefore, we decided that the Plan does not have to pre-
approve a service dog (S5199).
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 the enrollee is stable and will require 
extended acute care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can safely receive the care they need in the current hospital 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. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services provided to the enrollee on May 17, 2022.

You asked the Plan to pay for the laboratory testing services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the documentation does not support the billed date of service.

The Plan must follow Medicare rules. Medicare rules say that the general rule for the date of service (DOS) policy for either a clinical laboratory test or the technical component of physician pathology service is to bill the date the specimen was collected as the date of service. Maximus overturned the Plan's denial. The Plan requested a reopening stating that the specimen was obtained in a laboratory and has the incorrect date of service on the claim form. The claim shows a Place of Service of an independent laboratory. The rules state that the date of service submitted on the claim form must be the date the specimen was collected if the specimen was collected in a laboratory. The specimen was collected on May 2, 2022, but the date of service on the claim form was May 17, 2022.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing services provided to the enrollee on May 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronic acid injections. 
 
You asked the Plan to pre-approve hyaluronic acid injections. You say that you would like to know if you 
could have a referral for the shot. The Plan denied your request. The Plan says the hyaluronic acid injection is 
not medically necessary because six months have not elapsed since the prior 
hyaluronic injection. The Plan also says the medical records do not show any visits since the last injection on 
December 15, 2022, to confirm significant improvement in pain and functional capacity achieved with the prior 
series of injections using a standardized assessment tool. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation is considered not medically 
reasonable and necessary and will not be covered when a repeat series of injections is initiated prior to six 
months after completion of the previous course of treatment. 
 
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 hyaluronic acid injections. Our 
reviewer says that hyaluronic acid injections are not medically reasonable and necessary for the enrollee. Our 
physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. The record 
indicates that the enrollee received an injection in December 2022, and six months has not lapsed since the 
injection. Our reviewer found that the elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested service is not recommended. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyaluronic acid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyaluronic acid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services for the
enrollee.
You asked the Plan to pre-approve IRF services. You say that at the time of the appeal, IRF care was medically
necessary. The Plan denied your request. The Plan says the Medicare criteria for IRF care are not met.
Our Medical Director looked at the case file. At issue is coverage for IRF services. The enrollee was a then 82-
year-old man with a medical history that included heart disease, diabetes, and chronic kidney disease. The
enrollee was admitted to the hospital on February 7, 2023, with bilateral pneumonia and sepsis, with acute
hypoxic respiratory failure. The enrollee was discharged home on February 17, 2023. Also on February 17,
2023, the Physical Therapy Progress Note documents that the enrollee needed minimal assistance for transfer,
and supervision with ambulation with a rolling walker. The Occupational Therapy Progress Note documents
that the enrollee performed bed mobility with care giver assistance, transfers with minimal assistance and
ambulation with assistance using a rolling walker.
Based on the medical records provided, the documentation does not support that the complexity of the
enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The medical records also do not support that intensive
rehabilitation therapy with at least 3 hours of therapy per day at least 5 days per week is required in this case.
Medicare coverage criteria are not met.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve inpatient rehabilitation facility (IRF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81455) provided to the enrollee on
April 14, 2022.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that 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.
The Plan must follow Medicare rules. Medicare rules say that the general rule for the date of service (DOS)
policy for either a clinical laboratory test or the technical component of physician pathology service is to bill
the date the specimen was collected as the date of service. Maximus overturned the Plan's denial. The Plan
requested a reopening stating that the specimen was obtained in a laboratory and has the incorrect date of
service on the claim form. The claim shows a Place of Service of an independent laboratory. The rules state
that the date of service submitted on the claim form must be the date the specimen was collected if the
specimen was collected in a laboratory. The specimen was collected on March 17, 2022, but the date of service
on the claim form was April 14, 2022.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay
for the laboratory services (81455) provided to the enrollee on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services provided to the enrollee on
July 28, 2021.
You asked the Plan to pay for the laboratory testing services. You say that you disagree with the denial. The
Plan denied your request. The Plan says that there is no documentation that the specimen was collected directly
by 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 laboratory testing services
provided to the enrollee on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick collection system. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like to appeal this denial. 
The Plan denied your request. The Plan says incontinence supplies are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick collection system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy services (43236, 43239) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve esophagogastroduodenoscopy services. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of 
OON services have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The 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 
esophagogastroduodenoscopy services (43236, 43239) to be provided by an OON provider.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to hold you harmless for emergency room services provided on July 24, 2021.
You asked the Plan to hold you harmless for emergency room services provided on July 24, 2021 (minus any
contractual copayment). You say that the Plan should cover this care. The Plan denied your request. The Plan
says that their time to review this appeal expired due to a lack of medical records. Maximus upheld the Plans
denial. Maximus chose to reopen the case due to an error found with the prior decision.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan. The Plan follows these rules. You were provided with medical
care from a Plan contract provider. The Plan denied coverage for a lack of medical records. You would have no
control over the submission of medical records by a Plan provider. Any billing or medical record issues the
Plan requires resolution to would be between the Plan and the contract provider. Therefore, we decided that the
Plan has to hold you harmless for emergency room services provided on July 24, 2021 (minus any normal
copayment).
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 you fell out a bed breaking your vertebra and now 
you cannot get out of bed without assistance from a physical therapist. You say that you need physical, 
occupational and speech therapy as you are currently bedridden and are unable to get around. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary. 
 
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 your 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
met the coverage criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
enrollee does not meet the coverage criteria for Euflexxa. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Varenicline tablet. 
 
You asked the Plan to pre-approve Varenicline. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Varenicline 
tablet.  
 Benefits for Varenicline 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab, Pemetrexed, and Carboplatin for the enrollee.

You asked the Plan to pre-approve Pembrolizumab, Pemetrexed, and Carboplatin. You say that these drugs are medically reasonable for the enrollee's condition. The Plan denied your request. The Plan says that the use of Pembrolizumab, Pemetrexed, and Carboplatin for second line therapy of non-small cell lung cancer is not FDA approved or listed in the Medicare approved sources.

Our Medical director looked at the case file and the reopen request. At issues is coverage for Pembrolizumab, Pemetrexed, and Carboplatin. Our Medical Director states that there is insufficient clinical support for the use of pembrolizumab, pemetrexed, and carboplatin for second-line therapy of adenocarcinoma of the lung. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Pembrolizumab, Pemetrexed, and Carboplatin.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pembrolizumab, Pemetrexed, and Carboplatin have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab, Pemetrexed, and Carboplatin for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for the billed services. You say that intraoperative monitoring is considered 
medically necessary. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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, the CPT Code Manual definition of code 95822 is electroencephalogram (EEG); recording in coma 
or sleep only.  
 
 We find that CPT code 95822 is not supported in the medical record. Specifically, the records show that EEG 
services were provided during surgery, not in coma or sleep. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 95822 billed for date of service March 24, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the requirement for admission to an IRF. 
 
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 enrollee does not require intensive rehabilitation. The enrollee also does not 
require frequent physiatry oversight.  
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PD-L1 and PTEN genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that this is part of the enrollee's treatment plan. The 
Plan denied your request. The Plan says studies have not proven that this is helpful for treatment of the 
enrollee's condition. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found medical literature does not support this testing for gastrointestinal pathology or in the setting of 
rectal cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PD-L1 and PTEN genetic testing.