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

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the patient has on this drug in the past and didn't have 
any issues with bleeding.  She does have issues with bleeding being on Xarelto. The Plan denied your request. 
The Plan says this drug is not covered under the patient's medical benefits. 
 
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 Eliquis.  
 
Benefits for Eliquis 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: 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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH admission is not medically necessary. 
 
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 the provided record indicates that the enrollee has had a long and complicated 
hospital course. The record indicates that the enrollee continues to require ongoing acute care services. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that he is not currently receiving but that would be available at the 
LTACH facility. Therefore, the reviewer found that the LTACH care is not medically 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve darzalex faspro solution (J9144). 
 
You asked the Plan to pre-approve darzalex faspro solution. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Velcade. 
 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 darzalex faspro solution. Our reviewer 
says that the step therapy criteria have not been met. Our physician reviewer found the records provided the 
patient has not tried and failed the required drug. The reviewer found that there is no indication that the plan's 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of darzalex faspro solution have not been met. Therefore, we decided that the Plan 
does not have to pre-approve darzalex faspro solution (J9144).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close medical 
monitoring, daily physician management and prolonged as well as intensive skilled services that are not 
available at a skilled nursing facility. You say that the enrollee's medical care warrants an LTACH level of care 
to achieve a safe and sustainable discharge and she currently meets CMS guidelines. The Plan denied your 
request. The Plan says the requested LTACH services are not medically necessary. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (code 73600) provided on July 21, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this service was previously paid. Maximus overturned the Plans denial for a lack of
documentation of the previous payment. The Plan requested a reopen and stated that this claim denied because
this service was previously paid under another claim. This service was previously to the same provider for the
same date of service. There are no records to show why this procedure had been rendered twice on the same
day. The Plan provided documentation of both claims that show each claim was billed from the same physician
group. The correct billing of this service needed to include modifier 59, which is used to distinguish a different
session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate
injury.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems. Based on the documentation provided, this claim cannot be paid as it was billed twice by the same
physician group without the required modifier on the second claim. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for imaging services (code 73600) provided on July
21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removable partial denture you received on February 9, 2022. 
 
You asked the Plan to pay for the removable partial denture. You say that you believe this service was denied 
because the dentist was out of network. You stated that this dentist has been your provider since 1979 and you 
have confidence in his work. The Plan denied your request. The Plan says you were already covered for an 
upper partial denture on December 11, 2019, so you were not eligible for coverage of another denture on 
February 9, 2022. 
 
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. Your dental benefit includes 
coverage of removable partial dentures once every 5 calendar years.  You already received a covered 
removable partial denture in 2019, so you have exhausted that benefit for 5 years. 
 
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 pay for the 
removable partial denture you received on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 13, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan denied your request. The Plan says the Medicare billing criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan presented documentation to show that this claim denied because the provider billed this service
inappropriately. The Plan submitted specific documentation of only 17 drug classes counted from the
laboratory results received. The codes billed are only used when 22 or more classes were tested. The Plan states
there is another more appropriate code for the services provided.
The Plan is correct in this case. 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 Plan has
provided lab results to show less than 22 classes were tested, meaning this claim was not coded appropriately.
Medicare uses another code for testing resulting in less than 22 classes of drugs Therefore, we decided that the
Plan does not have to pay for drug testing provided to the enrollee on May 13, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for emergency room services
provided June 11, 2021, to June 12, 2021.
You asked the Plan to waive this copayment. You say that you were admitted to the hospital and should not
have to pay this copayment. The Plan denied your request. The Plan says you were admitted into observation
status, not as an inpatient and therefore the copayment applies. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct contract language.
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 $50 copayment for emergency room services unless you are admitted as an
inpatient to the hospital. The medical records show you were put into observation status and not full inpatient
status.
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 $50 copayment charged for emergency room services provided June 11, 2021, to
June 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography services provided to the enrollee from
April 5, 2021, to April 9, 2021, and billed under code 77014.
You asked the Plan to pay this claim. You say that this imaging should be covered by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that based on the Medicare billing guidelines, code 77014 is included in
the APC payment for code 77301 (IMRT planning).
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. Medicare does not allow
the billing of code 77014 in addition to the billing of code 77301. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for computed tomography services provided to the
enrollee from April 5, 2021, to April 9, 2021, and billed under code 77014.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180),
provided on May 11, 2021.
You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says while a portion of these services were paid, the comprehensive
periodontal evaluation is not covered. Maxims partially overturned the Plans denial for insufficient information
regarding the codes indicated to have been paid or for which you are not being billed. The Plan requested a
reopen and provided the required information.
The Plan is correct in this case. 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 more than Medicare coverage, the services denied are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive
periodontal evaluation (D0180).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on December 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the topical application of fluoride varnish, periodic oral evaluation, and prophylaxis. You say that in June 2021 the Plan mailed you a list of in-network dental providers. You also say that the provider you were treated by was selected from the list you were sent by the Plan. The Plan denied your request. The Plan says topical application of fluoride varnish is not a covered expense under your dental plan. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.

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, topical application of fluoride varnish is not among those covered under this benefit. The contract also says that you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on December 7, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily physician 
management with close medical monitoring and cannot be adequately cared for in his current condition at a 
skilled nursing facility. You say that he is suitable for transfer to an LTACH, and authorization should be 
granted. The Plan denied your request. The Plan says the enrollee's medical condition would be best served in a 
short-term acute care hospital. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available where he is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional physical therapy visits.
You asked the Plan to provide coverage for additional visits. You say that this therapy is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans denial because the case file lacked medical records. The Plan requested a reopen and submitted the
required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for 12 additional
Physical Therapy (PT) visits. The medical records show you had right total knee arthroplasty on June 2, 2021.
The records show the Plan covered 25 physical therapy visits through September 21, 2021. More visits were
requested. It is documented you had significant difficulty with balance and fear of walking without a device.
The goal was to graduate from a walker to cane to no device. You had not tried kneeling or a floor to stand
transfer at that point. It is documented that the enrollee would be discharged at that time but may require
additional skilled therapy services after a total hip replacement. The Plan is correct in this case. The additional
documentation provided does not support that the continued skills of a professional therapist were required at
that point.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does
not have to provide coverage for additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to pay for skilled nursing facility services provided from May 6, 2021, to
May 28, 2021.
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 the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient explanation of their decision. The Plan requested a reopen and provided additional claim
information. The Plan submitted documentation to show this claim denied because the provider has billed
these services inappropriately. The claim was billed with FBTD1; however, the provider should have billed
code FFVE for payment consideration. The provider attempted to submit a corrected claim with their appeal,
but the claim was still billed with the incorrect code.
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 this claim needs to be resubmitted to
reflect the correct FFVE code. Medicare billing criteria were not met. Therefore, we decided that the Plan does
not have to pay for skilled nursing facility services provided to the enrollee from May 6, 2021, to May 28,
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for aspiration of the pleural space (32555).
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 the Medicare billing criteria are not met. Maximus overturned the Plans denial for
insufficient claim information in the case file. The Plan requested a reopen and provided additional
information. The Plan says that procedure code 32555 is included within the global surgery package of
procedure code 36561 as this code has a global value of "000" on the CMS National Physician Fee Schedule
(NPFS) Relative Value (RVU) file. This is an endoscopy or minor procedure that has a global surgery period of
"0" days. Procedure code 36561was billed and paid by the Plan on June 07, 2021. Documentation of this
payment has been submitted.
The Plan is correct in this case. 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 Plan has
provided documentation to show this service was previously paid. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the aspiration of the
pleural space (32555) provided to the enrollee on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87798) provided to the enrollee on
August 24, 2020.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says code 87798 is not
payable due to Medicare guidelines and codes 87640 and U0003 were previously paid. Maximus overturned
the Plans denial for lack of claim information in the case file regarding code U0003. The Plan requested a
reopen and provided proof of payment for the code in question.

The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests,
except for the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.
Therefore, we decided that the Plan does not have to pay for the laboratory service (87798) provided on August
24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 13, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says they were unable to establish a relationship between the ordering physician and the
enrollee.
Maximus administratively overturned the Plans denial for insufficient information in the case file. The Plan
requested a reopen and provided additional information regarding their research of this claim. The Plan stated
per Medicare guidelines, diagnostic laboratory tests, and other diagnostic tests must be ordered by the
physician who is treating the enrollee. While the records include a physician order, there is no evidence that
this physician is treating the enrollee. The Plan provided documentation to show they made several attempts to
reach the ordering provider to determine their relationship to the enrollee's treatment. Those requests were not
responded to. Therefore, the Plan denied this claim based on Medicare billing requirements.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that Medicare
requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the
enrollee in accordance with Medicare's policies. Diagnostic laboratory tests must be ordered by the treating
physician. Tests not ordered by the physician who is treating the enrollee are not reasonable and necessary.
Based on the information provided, there is insufficient information provided with the claim to show the
ordering physician is treating the enrollee. Therefore, we decided that the Plan does not have to pay for genetic
testing provided to the enrollee on April 13, 2021.