Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the scans. We decided that the Plan does not have to pay for CT scan of 
the abdomen and pelvis.  
 
You asked the Plan to pay for the scans. You say that this is medically necessary. The Plan says that CT scans 
of the chest, abdomen and pelvis are not medically necessary unless a lymph node biopsy fails to establish a 
diagnosis. 
 
We decided that the Plan has to pay for CT scan of the chest.  
 The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 for the CT scan of the chest. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the CT scan of the chest is 
reasonable due to the swelling, palpable abnormality and prior abnormal thoracic imaging. Ultrasound would 
not necessarily give the appropriate information of the chest wall. 
 
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 scans have been met. Therefore, we decided that the Plan has to pay for CT 
scan of the chest.  
 
We also decided that the Plan does not have to pay for CT scan of the abdomen and pelvis. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 for the CT scans of the abdomen and pelvis. Our 
reviewer says that these scans are not medically reasonable and necessary. Our physician reviewer found 
deferring these scans makes sense pending biopsy results of the left axilla.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pay for CT scan of the abdomen and pelvis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 30, 2021. 
 
You asked the Plan to pay for drug testing. You say that the Plan made an error is denying this testing. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because the 
documentation does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for X-ray services provided on August 20, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for X-ray services. You say that these services were referred by the enrollee's 
physician. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and the ordering physician was also out-of-network with 
the Plan. 
 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 X-ray services provided on August 20, 2021 by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a rolling walker with supervision and is supervision for transfers. Provided records do 
not document a significant decline in the enrollees functional status to necessitate daily inpatient skilled 
therapy services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing 
facility setting. Services in the home with home health care or in a long-term care facility on a part time basis 
appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 22, 2021. 
You asked the Plan to pay for the testing services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on July 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PegFilgrastim. 
 
You asked the Plan to pre-approve PegFilgrastim. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not supported. 
 
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 PegFilgrastim. Our reviewer says that 
the requested use of PegFilgrastim is not supported. Our physician reviewer found the record indicates that the 
requested drug is being ordered for prophylaxis of febrile neutropenia. The chemotherapy regimen is 
Pemetrexed, considered a low risk for febrile neutropenia, and there is no indication that the enrollee is 
neutropenic. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition, and the Medicare approved cancer 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 PegFilgrastim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PegFilgrastim.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on October 
13, 2021, during which routine foot care was provided. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be paying 
a copayment for routine foot care. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 consultation, diagnosis, and treatment by a specialist.  
 
In this case, you do not owe any money for routine foot care. You have been asked to pay a $25 copayment for 
a specialist office visit. A specialist office visit falls 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) on October 13, 2021, during which routine foot care was provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not support 
that it is medically reasonable and necessary to provide skilled therapy services on a daily basis. As a practical 
matter, you do not require the necessary services on 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic risk panel provided on September 
27, 2021. 
 
You asked the Plan to pay for the cardiovascular genetic risk panel. You say that this is medically necessary 
testing. The Plan denied your request. The Plan says this is a noncovered screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
A test that is done in the absence of signs/symptoms of disease is considered a screening test. In this case, the 
enrollee's only reported diagnosis is hypertension. This is not a sign/symptom of cardiac disease, but rather a 
risk factor. Testing for genetic predisposition for heart disease is considered screening when the enrollee has no 
known diagnosis of heart disease or signs/symptoms of heart disease. This is among the limited screening tests 
that are covered by Medicare. Therefore, we decided that the Plan does not have to pay for the cardiovascular 
genetic risk panel provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to make payment for the outpatient hospital services provided from August 9, 
2021, through August 11, 2021. 
 
You asked the Plan to make payment for the outpatient hospital services. You say that this claim should not be 
denied based on these two codes. The Plan denied your request. The Plan says that the provider has only 
appealed codes 94640 and 94799 which were correctly denied due to a coding edit and are not eligible for 
separate payment on this claim. 
 
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. In this case, the Plan has argued that only codes 94640 and 94799 are at issue, as 
these codes were cited in the appeal request. However, Maximus finds that this is not supported. These two 
codes were denied due to an Outpatient Code Edit (OCE), which was used as the justification for the denial of 
payment of the entire claim. The edit that caused this denial is edit 15. The version of the Integrated Outpatient 
Code Editor in effect on this date of service indicates that this edit is "inactive". This would indicate that the 
presence of this edit should not cause the claim to be returned to provider and/or denied. As the Plan also 
indicates in its argument, these codes are listed with status indicator Q1, meaning that they are packaged (no 
additional payment made) when billed with other codes that have a status indicator of S, T, or V. Multiple other 
codes with these indicators are present on this claim. As such, the codes 94640 and 94799 would not have any 
effect on the total amount reimbursed on the claim. Based on the entirety of the information submitted, we find 
that the denial of this claim based on the edit invoked for these two codes is not appropriate. The edit itself is 
inactive, and the presence of these codes on the claim has no effect on the total outpatient prospective payment 
system (OPPS) reimbursement for the billed services. Therefore, we decided that the Plan has to make payment 
for the outpatient hospital services provided from August 9, 2021, through August 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed. The 
Plan denied your request. The Plan says the claim has not been billed with an appropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
August 26, 2021, have been met. Specifically, no medical records were received from the enrollees provider 
demonstrating the necessity of the requested services. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on July 29, 2021, and 
November 3, 2021, by an OON provider. 
 
You asked the Plan to pay for the pathology services. You say that the enrollee has no control over where the 
specimen is sent, as this is the only pathologist available at that location. The Plan denied your request. The 
Plan says the services were provided out-of-network and were not approved in advance. 
 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 the pathology services provided on July 29, 2021, 
and November 3, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 22, 2021. You asked the Plan to pay for the testing services. You say that the procedure was requested to help the 
enrollee treat her condition. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on September 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the enrollee has tried oral iron and had constant 
diarrhea. The Plan denied your request. The Plan says there is no documentation that the enrollee has tried and 
failed a preferred product or a medical reason why a preferred product cannot be used. 
 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 Feraheme. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step one alternative. Our reviewer also found that the record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).