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

 
We decided that the Plan does not have to pre-approve a minimally invasive sacroiliac (SI) joint fusion and an 
open SI joint fusion. 
 
You asked the Plan to pre-approve a minimally invasive SI joint fusion and an open SI joint fusion. 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 follows Medicare rules. Medicare rules say that minimally invasive surgical (MIS) fusion of the 
sacroiliac joint (SIJ) utilizing a lateral transfixation approach is considered medically necessary when specific 
criteria are 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 a minimally invasive SI joint fusion and 
an open SI joint fusion. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found minimally invasive Si joint fusion remains experimental for the treatment of degenerative back 
pain without SI joint instability, fracture, or lesion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a minimally invasive SI joint fusion and an open SI joint fusion have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a minimally invasive sacroiliac (SI) joint 
fusion and an open SI joint fusion.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Reblozyl (Luspatercept-aamt) for the enrollee.
You asked the Plan to provide coverage for the requested drug. You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Reblozyl (Luspatercept-aamt). The Maximus Physician Reviewer determined that while the requested use of Reblozyl is not FDA-approved for the enrollee's diagnosis, the use is supported by clinical research that appears in a medical journal. "Lancet Oncology (Volume 18, Issue 10, October 1, 2017) allows approval without ringed sideroblasts or packed red blood cell treatment requirements. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee."
The Plan requested a reopen and argues that "On review of the Lancet article, the study demonstrated results consistent with the Compendia and the package insert. Reblozyl has a role in treatment of enrollees with refractory anemia with ring sideroblasts." The medical records show the enrollee is a 70-year-old woman with a diagnosis of anemia secondary to myelodysplastic syndrome without ring sideroblasts. The Plan is correct in this case. Reblozyl is not FDA-approved for the enrollee's diagnosis of anemia secondary to myelodysplastic syndrome without ring sideroblasts, and its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does not support that Reblozyl is safe and effective and otherwise reasonable and necessary for the enrollee in this case. 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 requested drug have not been met. Therefore, we decided that the Plan does not have to provide coverage for Reblozyl (Luspatercept-aamt) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $277 copayment charged for outpatient nuclear medicine provided on November 17, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. 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 records and information. The Plan showed that this claim was for nuclear medicine, requested the Plan pay $991.85, with a $277 member liability. There is a 20% coinsurance for the drugs (code 636) equaling $2 and a $275 copayment for the nuclear medicine.
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 copayment for outpatient nuclear medicine and a coinsurance for Medicare Part B drugs. Code 78803 is described as Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT). This is billed as an outpatient nuclear medicine procedure. 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 $277 copayment charged for outpatient nuclear medicine provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84443, 36415, 80053, 80061) provided on May 
5, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (84443, 36415, 80053, 80061) provided on May 5, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on July 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 domiciliary services provided on July 22, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD requires 
that the pain relief from an epidural steroid injection lasts 3 months. This was not achieved and therefore, the 
request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomepra. 
 
You asked the Plan to pre-approve Esomepra. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Esomepra.  
 
Benefits for Esomepra 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 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 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 billing criteria.
Our Medical Director looked at the reopen request and the case file. At issue is the coding of code 75710 defined as Angiography, extremity, unilateral, radiological supervision and interpretation, and code 37221 defined as revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed. The Maximus Reviewer determined that the documentation supports separate payment for code 75710. Our reviewer found the documentation provided was reviewed, and it was found that criteria for separate payment have been met. This procedure would be separately reported, as code 37221 does not include radiology services. The Plan requested a reopen and stated that there is insufficient documentation in the operative report to approve the modifier requested. The operative report does not state the criteria required for approving the diagnostic angiography code. The medical records show the enrollee was a 75-year-old man with severe peripheral artery disease and a non-healing wound on his right lower extremity. The enrollee underwent successful placement of a right common iliac artery stent, and external iliac artery, common femoral artery, and deep femoral artery endarterectomy with patch angioplasty.
Our Medical Director has concluded that the Plan is correct in this case. Open and percutaneous interventional vascular procedures include operative angiograms and/or venograms, which should not be separately reported as diagnostic angiograms/venograms. Physicians shall not report radiologic supervision and interpretation codes, radiologic guidance codes, or other radiology codes where the radiologic procedure is integral to another procedure being performed at the same patient encounter, as in this case. Angiograms performed after angioplasty, stent, and atherectomy procedures are included in the interventional codes, and are not to be reported separately. Medicare billing criteria were not met. We looked at this coder'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 pay for imaging services provided to the enrollee on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $295 copayment charged for outpatient hospital services (trigger point injection) provided on September 29, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and the Plan contract agreement. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information.
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 $295 copayment for outpatient hospital services. The claim shows the provider billed this service with the Place of Treatment (POT) code of 131 which is for Outpatient Hospital.
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 $295 copayment charged for outpatient hospital services (trigger point injection) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (99442) provided April 5, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the telephone service was 
included in another service billed (99205). Based on this information, we decided that Medicare rules for 
coverage of the telehealth services have not been met. Therefore, we decided that the Plan does not have to pay 
for telehealth services (99442) provided April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L0650) provided March 29, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed services. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The exam notes do not note the provider prescribing the orthosis. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for an orthosis (L0650) provided March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active 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 inpatient psychiatric hospital services. 
Our reviewer says that the services are medically necessary. Our physician reviewer found based upon review 
of the records provided, the enrollee does meet criteria for acute inpatient mental health treatment as this 
enrollee was shown to be a danger to herself but not others. She had no auditory or visual hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital services.  
 
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: 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 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 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require, or to be able/willing to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services billed to the enrollee for November 18, 2021, under code 64999.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient medical records. The Plan requested a reopen and stated this was not a medical necessity issue and was reviewed for a coding issued. The Plan states that the claim has coding discrepancies based on the Medicare billing guidelines. The Plan noted the denial of the 79 modifier is due to the unlisted procedure code billed. The Plan states per the coding guidelines, CPT 64999 is not the appropriate code to bill for left endoscopic ulnar nerve decompression. The Plan demonstrated the March 2009 edition of CPT Assistant advised that it would be correct to report the procedure using code 29999 (Unlisted procedure, arthroscopy). The Plan states while code 64718 describes an open cubital tunnel release, there is no specific code to describe endoscopic cubital tunnel release. The Plan states the Medicare guidelines note it is not appropriate to report open surgical procedure code 64718 or 64719 for an endoscopic procedure as it is not acceptable to report a code for a procedure that is only like the actual procedure performed. Instead, code 29999 for "Unlisted procedure, arthroscopy," should be reported to follow Medicare coding guidelines.
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 cannot be paid as billed due to a discrepancy between the definition of the codes billed and the actual services provided. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for assisted surgical services billed to the enrollee for November 18, 2021, under code 64999.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 21,
2021, and billed under codes 37184, 37185, 37233, 75625, 75716 and 75774.
You asked the Plan to pay for this claim. You say that this claim should be paid by the Plan, The Plan denied
your request. The Plan says while part of this claim was paid, several codes were denied due to reporting errors
or because they were not supported in the medical record. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information.
The Plan says that codes 37184 and 37185 are not supported by the medical records submitted. The
thrombectomy procedure (37184 - 37186) is not separately reportable for removal of such thrombus. Therefore,
these codes cannot be verified. The atherectomy procedures have been approved in both the femoral - popliteal
and tibial vascular segments. Also, procedure codes 37184 and 37185 are column II codes with a modifier
indicator of 1 when billed with column I code 37227. The required modifier was not found on the claim.
Maximus agreed that the Plan does not have to pay for procedure codes 75716, 75625, and 75774.
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.
The Plan has shown that codes 37184 and 37185 were not billed appropriately. We previously found codes
odes 37233 and 75625 are not supported in the medical record. Specifically, there is no documentation of an
open or percutaneous endovascular revascularization of unilateral tibial/peroneal artery to support code 37233.
There is no documentation of radiological supervision and interpretation of an abdominal aortography by
serialography to support code 75625.
We also previously found the rules say that, for edits with a modifier indicator of 1, the Column 2 code is
payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 37227, 75716 and 75774. Codes 75716 and 75774 are
column II codes with a modifier indicator of 1 when billed with column I code 37227. The column II codes
were not billed with appropriate modifiers to allow for separate payment. The -XU modifier is not supported as
separate and distinct procedural service. Therefore, we decided that the Plan does not have to pay for surgical
services provided to the enrollee on September 21, 2021, and billed under codes 37184, 37185, 37233, 75625,
75716 and 75774.