Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator replacement battery procedure.
You asked the Plan to pre-approve the requested services. You say that the procedure is for a battery
replacement for the permanent implant. The Plan denied your request. The Plan says the battery was replaced
in July 2021.
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 the requested services. Our physician
reviewer found that the enrollee has a diagnosis of post-laminectomy syndrome, with radiculopathy in the
lumbar region. The scheduled procedure is for a battery replacement for the spinal cord stimulator implant. The
documentation is insufficient to demonstrate that a replacement battery procedure is medically reasonable and
necessary for the enrollee in this case. It would be reasonable to expect a battery life of several years to many
years in a spinal cord stimulator. It is not clear why a battery replacement in the spinal cord stimulator is
needed at this time.
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 services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a spinal cord stimulator replacement battery procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 20,
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 an edit exists between the two codes.
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 imaging services provided to the enrollee on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the remote monitoring of physiologic parameter(s), each 30 days (99454) provided on October 18, 2021 and November 17, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $25 copayment for Medicare covered primary care physician visits.

You have been asked to pay $50 ($25 copayment x 2) for the Medicare-covered primary care physician visits provided. 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 copayments for the remote monitoring of physiologic parameter(s), each 30 days (99454) provided on October 18, 2021 and November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on September 30, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $50 copayment for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay a $50 copayment for a specialist office visit. Specialist office visits fall within the Physician/Practitioner services, including doctor's 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 a specialist office visit (99213) provided on September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $475 copayment charged for a diagnostic colonoscopy
provided on June 18, 2021.

You asked the Plan to waive this copayment. You say that this was a screening and should be no charge. The
Plan denied your request. The Plan says the medical records show this claim was submitted by your provider as
a diagnostic colonoscopy which requires a surgical copayment. Maximus administratively overturned the Plans
denial due the lack of claim records in the file. The Plan requested a reopen and provided the required records.
The Plan confirmed your provider ordered this colonoscopy for a diagnosis of anemia and this service was
ordered to be done as soon as possible. The claim records confirm this service was neither ordered nor
performed as a screening.

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 a $475 copayment for outpatient surgical services. Based on the information
from your physician and the claim submitted by your physician, this was a diagnostic colonoscopy. 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 $475 copayment charged for a diagnostic colonoscopy provided on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 27, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $40 copayment for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay a $40 copayment for a specialist office visit. Specialist office visits fall within the Physician/Practitioner services, including doctor's 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 a specialist office visit provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (E2365, K0813).

You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 power wheelchair. Our reviewer says that the power wheelchair is not medically necessary. Our physician reviewer found there is no indication a home evaluation has been performed to ensure the patient's home is appropriate and safe for use of a power wheelchair.

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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (E2365, K0813).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve OPDIVO (J9299).
You asked the Plan to pre-approve OPDIVO. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not supported for the enrollee's condition.
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 OPDIVO. Our reviewer says that the
criteria for coverage of OPDIVO have been met. Our physician reviewer found though the requested use of
OPDIVO is not FDA-approved for the enrollee's diagnosis, the use is supported by clinical research that
appears in a CMS-approved medical journal in combination with FOLFOX for first line metastatic disease. The
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary
for this 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 OPDIVO have been met. Therefore, we decided that the Plan has to preapprove
OPDIVO (J9299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the enrollee suffers from diabetes and plantar fasciitis that creates numbness, tingling, and pain in the enrollees feet. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 7, 2021.

You asked the Plan to pay an additional amount for the eyeglasses. You say that you are entitled to $150 and that is reflected in the statement from the Plan, and that $150 was applied to the frames. You say that you have not used any of this benefit in this calendar year. The Plan denied your request. The Plan says the benefit of $150 allowance was applied to the purchase of the eyewear.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan has applied the eyewear benefit allowance of $150 to your purchase leaving you with a responsibility of $833. During the purchase of your eyeglasses, the facility was running a promotion that gave discounts for the 2nd pair of frames. A discount of $181.60 was applied to the $833 total charge, leaving you with the remaining balance of $651.40, which was paid at the time of purchase. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor for the enrollee.
You asked the Plan to provide coverage for a continuous glucose monitor for the enrollee. You say that a
continuous glucose monitor for the enrollee is medically necessary. The Plan denied your request. The Plan
says Medicare coverage criteria are not met. Maximus overturned the Plans denial stating the requested device
was medically necessary. The Plan requested a reopen and provided additional information. The Plan stated the
issue was medical necessity but that the enrollee does not meet all of the required coverage criteria. The Plan
also stated that at this point, the device has been approved for three weeks yet the enrollee has made no effort
to obtain the equipment. The records also show the enrollee has not been filling their insulin prescription and it
can be inferred the enrollee has not been testing blood sugars as required. The Plan also notes the enrollee has
been referred to financing if the issue is the expense.
The Plan is correct in this case. Medicare requires all of the coverage criteria listed to be met for this equipment
and supplies to be covered. Based on the information provided, the enrollee does not meet these criteria and did
not meet them at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage
for a continuous glucose monitor for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (CPT code A0998GY) provided to the enrollee on May 19, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is 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. CPT code A0998GY has a status code of "I". Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (CPT code A0998GY) provided to the enrollee on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Keytruda for the enrollee.
You asked the Plan to provide coverage for 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 the enrollee was diagnosed with
metastatic transitional cell carcinoma and metastatic non-small cell lung cancer. The requested use of Keytruda
is supported by the National Comprehensive Cancer Network (NCCN) compendia. 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 the use of Keytruda beyond 24 months is not FDA-approved, nor
is it supported in the Medicare compendia, available studies and tests, and package insert recommendations.
The medical records show the enrollee is a 62-year-old man with diagnoses of metastatic urothelial carcinoma
of the bladder with a T12 metastasis, and metastatic non-small cell lung cancer with a left axillary node
metastasis. The enrollee has been treated with Keytruda since April 4, 2018. While the enrollee has had an
excellent response to treatment, an increase in size of the NSCLC left axillary nodal metastasis on CT on
February 1, 2021. A course of radiation to the lymph node metastasis was completed on April 16, 2021. On
November 4, 2021, the treatment plan was to continue Keytruda for up to two years post-radiation.
Our Medical Director has concluded that the Plan is correct in this case. The FDA-approved label under the
heading Duration/Timing of Treatment: "Until disease progression, unacceptable toxicity, or up to 24 months".
The requested treatment regimen exceeds 24 months, and is therefore precluded, and not supported.
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 provide coverage for Keytruda for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for home health services for catheter changes.
You asked the Plan to provide coverage for this service. You say that this service is medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial stating this service was medically necessary. The Plan requested a reopen and stated that while the
catheter change was necessary, there is no indication that you are home bound and no medical reason to have
these services provided out of area.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that an enrollee must be
homebound for home health care services to be covered. The rules say only unforeseen care is covered out of
area. The medical records do not show that you are completely homebound. The issue was not the necessity to
have the catheter changed but the fact that you do not meet the Medicare rules or Plan contract rules for home
health services and/or out of network or out of area care. Therefore, we decided that the Plan does not have to
provide coverage for home health services for catheter changes.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Infliximab (J1745).

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 pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 provided records do not clarify if infliximab will be used concomitantly with other systemic therapy as required by the prior authorization criteria; methotrexate and acitretin are both listed on the enrollee's active medication list. 

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 (J1745).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two removals of an impacted tooth (D7220 x2) provided on October 21, 2021.
You asked the Plan to pre-approve the removals of an impacted tooth. You say that you have dental coverage since starting this plan and you made sure that you had the coverage before receiving this procedure. You also say that you feel you should not be responsible for the bill. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, 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 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 the two removals of an impacted tooth (D7220 x2) provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you meet Medicare criteria as you have type 2 diabetes, you test your blood glucose 4 times daily, you are on insulin, and your treatment regimen requires frequent adjustment based on blood glucose testing results. The Plan denied your request. The Plan says that you do not meet Medicare criteria.

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, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The plan did not provide any medical records in order to determine if the enrollee meets Medicare criteria for the requested continuous glucose monitor (CGM). Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).

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.