Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy needs are being met in the current skilled nursing facility.    The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You do not need to see a physical medicine and rehab physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute or complex rehab nursing needs noted in the record. At the current mobility status, the enrollee needs physical and occupational therapy but does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for inpatient mental healthcare after September 7,
2021.
You asked the Plan to provide coverage for inpatient mental healthcare. You say that inpatient admission for
mental health care was medically necessary at the time of the request. The Plan denied your request. The Plan
says Medicare coverage criteria were 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 inpatient
psychiatric care. Our Physician Reviewer determined that inpatient psychiatric case was medically
necessary. The Plan requested a reopen and notes that you were being treated with a low dose of quetiapine and
had refused it (not on a regular basis) as it caused insomnia, even though it was being prescribed for insomnia.
The Plan notes that this was not the primary medication, and when a suggestion was made to consider
switching it to the morning, you were confused. The Plan states that this was due to underlying dementia, and
given that the symptoms of dementia were chronic, longstanding, and not expected to improve at this level of
care, it was determined that you had reached reasonable expectations for improvement. You were medically
stable and did not meet criteria for 24-hour inpatient care. Our Medical Director says that the Plan is correct in
this case. The Plan covered inpatient psychiatric care from August 27, 2021, to September 6, 2021. Based on
the medical records, as of September 7, 2021you had no thoughts to harm yourself or others. While your
memory was impaired, the documentation does not support that you required continued inpatient psychiatric
services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental healthcare have not been met. Therefore, we decided that the
Plan does not have to provide coverage for inpatient mental healthcare after September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cardiac catheterization for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has no signs or symptoms of cardiac disease.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The patient has been asymptomatic. A stress test has not been performed. Documentation does not support the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  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 pre-approve cardiac catheterization for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a new CPAP machine due to recall of the
current equipment.
You asked the Plan to provide coverage for a new CPAP machine. You say that your CPAP machine was
recalled, and the Plan should provide you with a new one.
The Plan denied your request. The Plan says there is no indication that you attempted to obtain loaner
equipment from the provider or that your equipment could not be used until such time that repairs were
provided. The Plan states this equipment was provided in February of 2021 and was new at that time. Maximus
overturned the Plans denial stating the rules indicate the Plan must provide new equipment as continuity of
care. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say Medicare covers
equipment only when it is reasonable and necessary. If equipment serves the same purpose as equipment
already available to an enrollee, it is not considered reasonable and necessary. This was not a continuity of care
issue. The file shows that you were provided with a new CPAP machine in February of 2021. In September of
2021 you requested a new machine due to a provider recall. However, there is no indication that your current
equipment was not working or that you were not being provided loaner equipment by the provider or warrantor
while yours was being repaired due to the recall. The Plan is only required to intercede and pay for replacement
equipment from another provider when the current equipment provider is not able to loan you equipment or fix
your current equipment within a reasonable amount of time. Therefore, we decided that the Plan does not have
to pre-approve a new or full replacement for a continuous positive airway pressure (CPAP) machine due to
recall of the current equipment.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on April 2, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face services.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea for the enrollee.  You asked the Plan to pre-approve Eylea. You say that this is medically necessary to treat the patient's exudative age-related macular degeneration in right eye with active choroidal neovascularization. The Plan denied your request. The Plan says that the member has not tried and failed the preferred step therapy drug.  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 Eylea. Our reviewer says that Eylea is not medically reasonable and necessary. The Plan requires a trial of bevacizumab before they will approve Eylea. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Eylea.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for full hereditary cancer genetics panel testing provided on May 11, 2021.  You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denied coverage when a laboratory assays two or more genes in a single panel  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.  The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for full hereditary cancer genetics panel testing provided on May 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion of methylprednisolone provided to the enrollee on
April 21, 2021, billed under codes 96413 and 96415.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billed criteria were not met. Maximus overturned the Plans denial for not
substantiating their denial with medical records.
The Plan requested a reopen and stated that no medical records were received from the provider despite
multiple requests for said information. This Plan states this is an administrative determination for coding and is
not based on clinical criteria for medical necessity; medical records have no implication on these billed
charges. The enrollee underwent an infusion of methylprednisolone on April 21, 2021. Codes 96413 and 96415
were denied as there are more appropriate codes to describe the services provided. These codes represent
administration of a chemotherapeutic medication to combat malignant neoplasms. The enrollee received an
infusion of methylprednisolone, a steroid medication, for rheumatoid arthritis. There was no record or
indication of a malignancy diagnosis, nor was one listed on the claim form. This claim cannot be paid as the
codes used were not appropriate for the services described and/or billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, the appropriate codes were not used for
payment of these services. In addition, non-contract providers are required to provide the appropriate medical
records to support the services billed. The Plan would not have direct access to these records and cannot be
held responsible for them. The Plan states records were requested but were not received. 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 infusion of methylprednisolone provided to the enrollee on April
21, 2021, billed under codes 96413 and 96415.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).  You asked the Plan to pre-approve the service. You say that your multiple doctors tell you this is a viable solution to your pain. The Plan denied your request. The Plan says that your request is not medically necessary because your records show you have not had maximal medical management. The Plan states there is no documentation of recent physical therapy or recent injections.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 to pre-approve the service. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is NO statement in the NCD or LCD that failed therapies need to be retried. You meet all of the criteria, and it is medically reasonable and necessary.  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 service have been met. Therefore, we decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a MyoPro powered arm brace.  You asked the Plan to pre-approve the MyoPro powered brace. You say that this will be helpful as the enrollee is not making progress with the current treatments. The Plan denied your request. The Plan says there is insufficient literature to support the use of this device.  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 MyoPro powered brace. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found no medical records from the enrollee's treating physician have been provided explaining why the requested device is the most appropriate treatment for the enrollee's condition. There is a lack of well-controlled studies showing a long-term benefit of the requested device for treatment of traumatic brain injury. Current clinical stroke guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.   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 MyoPro powered brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro powered arm brace.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on April 28, 2021.  You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records provided do not show that the enrollee specimen was obtained at the independent laboratory. 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 April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81206, 81210, 81292, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194, 81309) provided May 11, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 81206, 81210, 81292, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194 and 81309 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.  Therefore, we decided that the Plan does not have to pay for lab services (81206, 81210, 81292, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194, 81309) provided May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 16, 2021, under the
Medicare benefit.
You asked the Plan to pay the entire cost of these services. You say that these services should be covered by
the Plan. The Plan denied your request. The Plan says this cost share was applied based on your dual eligibility.
Maximus overturned the Plans denial. The Plan requested a reopen and stated this claim was processed towards
your Medicaid benefits. The Plan provided documentation to show that you are Medicaid Eligible and that this
claim was submitted to Medicaid for payment. Any concerns regarding the cost share must be addressed
through Medicaid.
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 you are a dual eligible member. This claim was submitted to and processed under your Medicaid
benefit. Neither the Plan nor Maximus has the authority to waive this cost share as we can only review those
services that apply to your Medicare benefit. Therefore, we decided that the Plan does not have to pay for
physician services provided on April 16, 2021, under the Medicare benefit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.    The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.