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

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda 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 Keytruda
(Pembrolizumab). The Maximus Physician Reviewer determined that Keytruda was medically reasonable and
necessary for the enrollee. The Plan requested a reopen and argues that there is no established evidence to
support the use of single-agent therapy with Keytruda for metastatic esophageal adenocarcinoma that is MSSstable,
MMR proficient, and no evidence of "MSI-H or dMMR".
The medical records show the enrollee is an 84-year-old man with a diagnosis of cT3N0 invasive
adenocarcinoma of the mid to distal esophagus. The enrollee was treated with chemotherapy and radiation,
with resultant significant neuropathy. Imaging studies on November 1, 2021, demonstrated esophageal wall
thickening, new hypermetabolic lymph node consistent with nodal metastasis, and numerous small pulmonary
nodules suspicious for pulmonary metastases. Single agent Pembrolizumab has been recommended for
palliative treatment.
Our Medical Director has determined that the Plan is correct in this case. Keytruda is not FDA approved for the
enrollee's diagnosis. Keytruda is FDA-approved for the treatment of recurrent locally advanced or metastatic
PD-L1-expressing (combined positive score 1 or greater) gastric or gastroesophageal junction adenocarcinoma
with disease progression on or after 2 or more prior fluoropyrimidine- and platinum-containing chemotherapy
regimens, and HER2/neu-targeted therapy if appropriate. The case file does not contain documentation
regarding PD-L1 expression or HER2 status. Use of Keytruda in this case is not supported by one of the major
drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list
of CMS-approved journals). The documentation is insufficient to demonstrate that Keytruda is reasonably
expected to be 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the tanks you currently receive 
are too heavy for activities outside the home. The Plan denied your request. The Plan says services that are 
considered redundant to equipment you already have are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cell enumeration using immunologic selection and 
identification in fluid specimen (86153) provided on December 20, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached medical records 
and reconsider the claim for payment. The Plan denied your request. The Plan says the information provided 
does not support the need for this service or item per CMS. Enrollees must receive their medical services from 
an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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 cell enumeration using immunologic selection and 
identification in fluid specimen (86153) provided on December 20, 2021 by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge (99217) provided on 
November 18, 2021. 
 You asked the Plan to pay for the observation care discharge. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the qualifying initial or 
subsequent observation care, or other service resulting in an observation stay has not been reported. 
 
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 99217 is not supported in the record. Specifically, the documentation submitted does 
not indicate that a qualifying observation care code has been reported. Based on this information, we decided 
that Medicare rules for coverage of the observation care discharge have not been met. Therefore, we decided 
that the Plan does not have to pay for the observation care discharge (99217) provided on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 14, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appropriate modifier was not billed. 
 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, we have confirmed that code 70481 
is a column II code to column I code 70470. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on October 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from
May 31, 2021, to June 4, 2021.
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 as of May 31, 2021, the enrollee no longer required these services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 pay for these services. Our physician reviewer found that the enrollee is a 69-year-old
female with pyelonephritis and bronchitis. From a nursing perspective, the enrollee received oral
medications. The enrollee had stable vital signs. She was continent of bowel and bladder. Regarding
rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT). By the
dates in question, the enrollee was at a modified independent level with functional mobility including gait to
100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no
identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee
does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting
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 pay for skilled nursing facility services provided to the enrollee from May 31, 2021, to June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
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 in this case the enrollee was admitted for a total hip arthroplasty and developed 
hypoxic respiratory failure in the setting of a history of crypotogenic organizing pneumonia. The record 
indicates that the enrollee continues to require high flow oxygen due to oxygen desaturation and requires 
ongoing acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056), implant supported 
crowns (D6066), and surgical implant placement (D6010) to be provided by a participating provider. 
 
You asked the Plan to pre-approve prefabricated abutments, implant supported crowns, and surgical implant 
placement. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says 
D6056, D6066, and D6010 are not covered dental 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. 
 
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 prefabricated abutments (D6056), implant supported crowns (D6066), and surgical implant placement (D6010) 
to be provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Udenyca.
You asked the Plan to provide coverage for Udenyca. 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 Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Udenyca
(Pegfilgrastim-cbqv). The Maximus Physician Reviewer determined that the use of Pegfilgrastim such as
Udencya is generally recommended to reduce the risk of neutropenic fever when the anticipated risk of
neutropenic fever for a chemotherapy regimen is approximately 20% or higher. The Plan requested a reopen
and stated that you were receiving a chemotherapy with concurrent radiation therapy regimen that is considered
low risk for developing neutropenic fever.
The medial records show you have a diagnosis of squamous cell carcinoma of the larynx. On October 29, 2021,
it is documented that you would begin "chemoRT" with high-dose cisplatin.
Our Medical Director has determined that the Plan is correct in this case. The documentation is insufficient to
support that Udenyca is medically reasonable and necessary and was expected to be safe and effective 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 Udenyca have not been met. Therefore, we decided that the Plan does not
have to provide coverage for Udenyca.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond
January 21, 2022.
You asked the Plan to pre-approve continued SNF services. You say that at the time of the appeal, continued
SNF services were medically necessary. The Plan denied your request. The Plan says the medical records no
longer indicated a need for inpatient skilled nursing or skilled therapy care as of January 21, 2022.
Maximus administratively overturned the Plans denial because a notice of non-coverage had not been
submitted with the case file. The Plan requested a reopen and submitted the required documentation to show
notice was properly delivered.
Based on the documentation provided, the Plans denial was correct in this case The Plan must follow Medicare
rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules
section are met. Custodial care is not covered. Based on the medical records, at the time of the appeal your
needs were custodial in nature, and you no longer required daily skilled nursing or daily skilled therapy service
at an SNF facility 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 continues SNF services have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) services beyond January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an annual physical exam provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for an annual physical exam. You say that you are being charged a 
$10 copayment for your annual physical exam. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $10 copayment for a primary care visit. The Plan contract also says that enrollees pay a $0 copayment for an annual 
physical. The contract also says if you receive services that address a medical condition during the same office 
visit, additional cost-share may apply. 
 
The medical record shows that you received services that addressed a medical condition during your annual 
physical on December 13, 2021. Therefore, an additional cost sharing amount applies. You have been asked to 
pay a $10 copayment for an annual physical exam. An annual physical exam falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 copayment for an annual physical exam provided on December 13, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the cost for the heart muscle imaging with injection provided on October 
25, 2021. 
 
You asked the Plan to waive the cost for heart muscle imaging with injection. You say that you were not aware 
there was a copayment/co-insurance for the test. The Plan denied your request. The Plan says that cost is 
correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not submit approved amounts for the services billed. 
Without an approved amount for each service, we cannot determine that the cost you are being asked to pay is 
correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the cost for the heart 
muscle imaging with injection provided on October 25, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infliximab. 
 
You asked the Plan to pre-approve Infliximab. You say that Infliximab is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Infliximab. Our reviewer says that 
Infliximab is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of scleromalacia perforans. The Food and Drug Administration has not stated that the requested drug 
is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infliximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Infliximab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is medically necessary. The Plan denied 
your request. The Plan says a trial of Euflexxa and Synvisc is required before alternatives can be considered. 
 
 
 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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity revascularization of the left iliac, 
femoral and popliteal arteries. 
 
You asked the Plan to pre-approve lower extremity revascularization of the left iliac, femoral and popliteal 
arteries. You say that the requested service is medically necessary. The Plan denied your request. The Plan says 
there is no documentation of imaging studies confirming >50% blockage of these vessels. 
 
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 lower extremity revascularization of the 
left iliac, femoral and popliteal arteries. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for angiography and revascularization of the left iliac, femoral 
or popliteal arteries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity revascularization of the left iliac, femoral and popliteal arteries 
have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity 
revascularization of the left iliac, femoral and popliteal arteries.