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

 
We decided that the Plan does not have to pre-approve Nuplazid. 
 
You asked the Plan to pre-approve Nuplazid. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under 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 Nuplazid.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental appointment to be rendered by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dental appointment. You say that you would like to see these OON 
providers on an in-network status. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a dental 
appointment to be rendered by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that at the time of the appeal, additional transportation was medically necessary. The Plan denied your request. The Plan says you had exhausted the 24-trip maximum. Maximus overturned the Plans denial for a lack of trip information to confirm the benefit was exhausted. The Plan requested a reopen and provided a copy of the trip report.
The Plan is correct in this case. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. Based on the records provided, you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for out of network dental services provided on November 29, 2021.
You asked the Plan to pay for these services. You say that you had exposed nerves from a broken crown and needed to see someone quickly. The Plan denied your request. The Plan says you did not have prior authorization for out of network dental care. Maximus overturned the Plans denial because the case file did not include a plan contract for review. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says dental services must be obtained from in network dental providers. The 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 out of network dental services provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services provided on February 8, 2022.
You asked the Plan to pay for refraction services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says refraction services are not covered. Maximus overturned the Plans denial as the wrong Plan contract was submitted for review. The Plan requested a reopen and provided the 2022 contract.
The Plan is correct in this case. Medicare does not cover refraction services. The Plan does not cover refraction services. The services in question are refraction services. Therefore, we decided that the Plan does not have to pay for refraction services provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five custom fabricated abutments (D6057 x5) and five 
abutment supported porcelain fused to metal crowns (D6059 x5). 
 
You asked the Plan to pre-approve the custom fabricated abutments and abutment supported porcelain fused to 
metal crowns. You say that last year you were told that dental implants were covered, but now midway 
through, you are being told it is not covered. You also say that you currently have the metal posts inserted but 
are having trouble eating. The Plan denied your request. The Plan says these services are not covered under 
your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve five 
custom fabricated abutments (D6057 x5) and five abutment supported porcelain fused to metal crowns (D6059 
x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam (CT) scan provided on October 13, 2021.
You asked the Plan to pay for an oral exam and a cone beam CT scan. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says while the oral exam was covered, the cone beam CT scan is not a covered benefit. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that the oral exam was approved prior to our decision.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan covers the oral exam that was provide, the cone beam CT scan is not a covered benefit.
Therefore, we decided that the Plan does not have to pay for an oral exam (D0140) and cone beam computed tomography (CT) scan provided on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for inpatient care provided from November 7, 2021, to November 11, 2021.
You asked the Plan to waive this copayment. 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 overturned the Plans denial for a lack of medical records. The Plan requested a reopen and provided documentation to show inpatient care was provided for the dates in question.
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 $445 per day for days 1 to 3 of an inpatient stay.
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 copayment charged for inpatient care provided from November 7, 2021, to November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provide to the enrollee on November 27, 2021.
You asked the Plan to pay for this testing. 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 Medicare criteria. The Plan states that s denied because this service was billed with an inappropriate diagnosis code. The Plan states the provider billed this service with diagnosis code C25.9 for Malignant neoplasm of pancreas, unspecified. The Plan states this diagnosis is not included in the LCA Article A56199 under the Group 3 codes which show the appropriate diagnosis codes that should be submitted with this service. The appealed claim shows the provider billed this service inappropriately.
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 diagnosis codes.
In this case, this claim was not submitted with a valid diagnosis code for the testing reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provide to the enrollee on November 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Blenoxane- Bleomycin sulfate injection (J9040). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the use of Bleomycin sulfate injection for basal cell carcinoma is not FDA 
approved or listed in the Medicare approved sources. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the requested use of Blenoxane- Bleomycin sulfate injection (CPT code J9040) is not FDA-approved for 
the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Blenoxane- Bleomycin sulfate injection (J9040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that the enrollee has uncontrolled diabetes. The Plan 
denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. 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 a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. 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 an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 PET scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found per NCD 220.6.13 states that 
an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and 
documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. All 
other uses of FDG PET for patients with a presumptive diagnosis of dementia-causing neurodegenerative disease for which CMS has not specifically indicated coverage. The service continues to be noncovered. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain.
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 you are requesting inpatient rehabilitation services so 
you can return safely to your prior level of function and maximum potential. 
 The Plan denied your request. The Plan says rules for IRF care have 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 that your nursing, medical and rehabilitation needs do not require an acute rehab 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. Although you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement, the documentation does not support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain your functional status. You can receive further services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the cervical, thoracic 
spine (64633, 64634). 
 
You asked the Plan to pre-approve the RFA. You say that the requested injections are medically necessary. The 
Plan denied your request. The Plan says the frequency limitation of two radiofrequency sessions per rolling 12 
months has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the RFA have not been met. Specifically, the file indicates that the enrollee has already had 2 
sessions of RFA at the same anatomic region on September 28, 2021, and November 2, 2021. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the cervical, thoracic 
spine (64633, 64634).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided to the enrollee on November 4, 2021.
You asked the Plan to pay for this claim as billed. You say that these services 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 for a lack of claim information in the file. The Plan requested a reopen and provided additional information. The Plan shows the provider has billed this service with the incorrect Place of Service (POS) code. The claim image that shows the provider has billed the POS as 22 for Outpatient Hospital. The referring claim image that shows the enrollee was in Inpatient Hospital during dates of service October 13, 2021, to November 16, 2021, as the Bill Type Code is listed as 111 for Inpatient Hospital.
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 place of service code. In this case, this claim cannot be paid as billed due to an inappropriate POS code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for x-ray services provided to the enrollee on November 4, 2021.
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 you had a stroke and need IRF care. The Plan denied 
your request. The Plan says there is no documentation of a mobility and functional activity limitation requiring 
at least minimum assistance with activities of daily living, cognition, language/speech, or swallowing function. 
Your needs can be met at a lower level of care. 
 
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 in this case, the complexity of your nursing, medical and rehabilitation needs 
does not require an IRF stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an IRF.  There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain his functional status.  You can receive further services at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine items and services or outpatient therapy charges 
billed on the inpatient claim for services rendered on June 25, 2021, through August 4, 2021. 
 
You asked the Plan to pay for the routine items and services and outpatient therapy charges. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these 
items are considered routine items and services or not supported by the records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge. The rules also 
say that the information submitted by the supplier or provider must corroborate the documentation in the 
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. o 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the routine items and services and outpatient therapy charges have not been met. Specifically, the 
items at issue are considered routine items and services or are not supported in the medical records submitted. 
Therefore, we decided that the Plan does not have to pay for the routine items and services billed as  BAN  
Nebulizer Disp, Blade CL 2, Blade CL 5, Blade CL 9, Cable Patient Lead Disp, Capnigraph Daily, Cath Inline 
Suction, Cerebral Oximeter Disposable, CV Fogarty Softjaw Insert, CV Teflon Pledgets, Disposable Ambu, 
EMG Endotracheal Tube 27-31 Fr, Flutter Valve (Disp), HR US Tray, Thora/Paracentesis, HR US ZZ Urinary 
Supplies, HR ZZ CT Autoinjector Syringe, HR ZZ US NDL Centesis/Drain Cath, Incentive Spirometry, Inline 
Cath Aspiration/Nasotrache, MDI/HHN Demonstration & Eval, MDI/HHN/Sputum Induct EA Treatment, 
Nasal Smart Capnoline, Oximetry Spot Check-One Time Only, Packing CL 2, PAPB Treatments EA, POCT 
Blood Glucose Test Each, Radial Artery Cath 20g AW RA 0402, Ratio Applicator for PRP Admin, Set, IV 
Primary Pump Plum 51674, Spacer (Disp), Staplers, Sutures, Transducer, Venipuncture, Vent Parameters and 
Vent Volume/Pressure Vent Supply and outpatient therapy services billed as  PT Eval, PT Gait Training, PT 
Home Management, PT Re- Evaluate Established POC, PT Therapeutic Activities, PT Therapeutic Exercises 
billed on the inpatient claim for services rendered on June 25, 2021, through August 4, 2021.