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

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care provided from 
May 30, 2021, to June 5, 2021. 
 You asked the Plan to pre-approve the SNF care. You say that it is felt that Medicare payment should be paid 
for the dates at issue. The Plan denied your request. The Plan says the services provided during this date span 
were custodial in nature. 
 
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 pre-approve the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented 
skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee was 
ambulating more than 100 feet and tending to daily living activities with minimal supervision. Daily skilled 
services were not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs could be provided 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care provided from May 30, 2021, to June 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service September 3, 
2021. 
 You asked the Plan to pay for procedure code 76882. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says payment for this code is bundled into payment for another 
code billed on the same date of service. 
 
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 76882 
is a column II code to column I code 76642. 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 procedure code 76882 billed for date of service September 3, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy with a biopsy provided on 
June 23, 2021. 
 
You asked the Plan to waive the copayment for the endoscopy with a biopsy. You say that you should not be 
responsible because it was a preventative procedure. The Plan denied your request. The Plan says the cost 
sharing applied is correct. 
 
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 $390 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center.  
 
  
You have been asked to pay a $390 copayment for the endoscopy with a biopsy. The biopsy falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 the endoscopy with a 
biopsy provided on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 4, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
another code billed on the claim. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service November 4, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
July 29, 2021. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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 70450 
is a column II code to column I code 70496. 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 the Computed tomography (CT) scan (70450) provided on July 
29, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Injectafer. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drug(s). There is no documentation provided indicating that the plans required drug(s) would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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 a portable oxygen concentrator 
will save money. The Plan denied your request. The Plan says that you are not covered for a second portable 
oxygen system. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a home oxygen concentrator and portable oxygen tanks. A home oxygen 
concentrator and portable oxygen tanks serves the same purpose as a portable oxygen concentrator. Therefore, 
we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on March 4, 2021. 
 You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an 
out-of-network provider on November 9, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were referred by your dentist. 
You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says one 
comprehensive oral evaluation is allowed every three years. 
 
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. The Plan covers one 
comprehensive oral evaluation every three years.  
 
We looked at the file and Medicare rules. Evidence was provided that shows D0150 was provided on July 28, 
2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) provided by an out-of-network provider on November 9, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the adrenoleukodystrophy genetic testing provided on March 29, 2021. 
 
You asked the Plan to pay for the adrenoleukodystrophy genetic testing. You say that the enrollee required this 
testing to assess for a genetic component to her condition. The Plan denied your request. The Plan says that 
screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or 
disease predisposition are not a benefit and are not covered. This cannot be overridden by Plan-directed care. 
 
Please note: Maximus reviewed the Plans argument, and we find no basis to consider this an excluded 
screening test. The documentation provided shows that this enrollee was being evaluated for neurological 
issues in the presence of a family history of adrenoleukodystrophy. Testing for a genetic component to explain 
symptoms cannot be considered a screening service. As such, Plan-directed care would apply to this testing.  
 
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 unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the adrenoleukodystrophy genetic testing by a contract provider. The file does not 
show that the plan provided notice that the adrenoleukodystrophy genetic testing would not be covered. Under 
Medicare rules, this means the adrenoleukodystrophy genetic testing is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for the adrenoleukodystrophy genetic testing provided on March 
29, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission from March 8, 2022, 
forward. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that you need 
continued inpatient psychiatric care. The Plan denied your request. The Plan says under Medicare guidelines, 
this request is not medically necessary. 
 
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 a continued inpatient psychiatric 
admission. Our reviewer says that the continued inpatient psychiatric care from March 8, 2022, forward is not 
medically necessary. Our physician reviewer found that you did not appear to require inpatient mental health 
treatment beyond the date in question as you were not a danger to yourself or others and do not have auditory 
or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It 
did not appear that the services were reasonably expected to improve your condition or for the purpose of 
diagnosis beyond the date in question. It appears that the records were supervised and evaluated by a physician. 
Based upon review the records provided for your admission, you do not meet the criteria for March 8, 2022, 
forward, as you were not shown to be a danger to yourself or others, delusions, auditory or visual hallucinations 
noted. You were cooperative/compliant with treatment while not showing any threats to safety. 
 
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 continued inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an inpatient psychiatric admission from March 8, 2022, 
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on October 26, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
separately payable.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the requested critical care service is included in the 
global surgery payment for the procedure (36558) provided on October 25, 2021. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services (99291) provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stalevo. 
 
You asked the Plan to pre-approve Stalevo. 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 Stalevo.  
 
 
 
 Benefits for Stalevo 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy administration into the peritoneal cavity 
via indwelling port or catheter. 
 
You asked the Plan to pre-approve chemotherapy administration into the peritoneal cavity. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 chemotherapy administration into the 
peritoneal cavity. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the service is controversial. It can be used after 
R0(complete resection). The enrollee has not had complete resection. The service is not medically necessary 
and is experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chemotherapy administration into the peritoneal cavity have not been met. 
Therefore, we decided that the Plan does not have to pre-approve chemotherapy administration into the 
peritoneal cavity via indwelling port or catheter.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says that the requested drug is not being prescribed for a medically 
accepted indication. 
 
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 Tecentriq. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found in this case, the requested 
use of Tecentriq is FDA-approved for the enrollees diagnosis. It is approved for maintenance therapy after 
chemotherapy with atezolizumab in extensive stage small cell lung cancer and systemic disease is controlled on 
recent computed tomography (CT) scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have been met. Therefore, we decided that the Plan has to pre-
approve Tecentriq.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on November 16, 202. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that a corrected claim 
was not submitted timely. 
 
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. The Plan argues that the corrected claim was not submitted within the one-year 
time limit. However, the submitted documentation does not show when the corrected claim was submitted. 
Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the 
Plan has to pay for the services provided on November 16, 202.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for inpatient hospital services provided 
from March 21, 2021, to March 27, 2021. 
 
You asked the Plan to provide additional payment for the inpatient hospital services. You say that this 
diagnosis is supported by the medical record, so the Plan should pay you at the Diagnosis Related Group 
(DRG) billed. The Plan denied your request. The Plan says the DRG you billed is not supported because the 
diagnosis of E43 (severe protein calorie malnutrition) is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis of E43 (severe protein calorie 
malnutrition). 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 provide additional payment for the 
inpatient hospital services. Our reviewer says that diagnosis E43 (severe protein calorie malnutrition) is not 
supported by the medical record. Our physician reviewer found the patient presented with an overweight body 
mass index (BMI) of 27.2kg/m2, without confirmed report of weight loss and with an unspecified subjective 
report of muscle wasting. There is no documentation of unintended weight loss by either the patient or their 
physician. In accordance with Global Leadership Initiative on Malnutrition (GLIM) Guidelines for 
malnutrition, the diagnosis of Severe Malnutrition requires documentation of one of the following phenotypic 
traits: a BMI of less than 21.0kg/m2 for age greater or equal to 70 years, greater than 10% weight loss over the 
past six months, greater than 20% weight loss beyond six months, or the presence of severe muscle wasting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to 
provide additional payment for inpatient hospital services provided from March 21, 2021, to March 27, 2021.