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

We decided that the Plan does not have to pre-approve Evenity for the enrollee.
You asked the Plan to pre-approve Evenity. You say that Evenity 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 Evenity
(Romosozumab-aqqg). The Maximus Physician Reviewer determined that the medication is medically
necessary for the enrollee in this case. The reviewer determined that the documentation supports that the
Evenity is medically reasonable and necessary for the enrollee. The documentation supports that the Evenity is
safe and effective for the enrollee.
The Plan requested a reopen and states that Evenity has a lifetime limit of 12 doses. The Plan notes that the
enrollee had already received 6 doses of the medication, and the plan made a decision to allow only 6
additional doses, for a total of 12 lifetime doses, and not a total of 18 doses.
Our Medical Director has concluded that the Plan is correct in this case. The medical records show the enrollee
is a 55-year-old woman with a diagnosis of Age-related osteoporosis without current pathological fracture. The
plan approved 6 doses of Evenity over 6 months and denied an additional 6 doses of the drug over 6 months.
The FDA-approved label for Evenity states, "Limitations of Use: Limit duration of use to 12 monthly doses."
The Plan appropriately approved 6 additional doses of Evenity, for a total of 12 doses. The Plan appropriately
denied additional doses of the drug above 12.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nitrous oxide (D9230) provided on November 12, 2021.  You asked the Plan to pay for the dental service. You say that grinding a tooth away should be considered a lot of dental work. You say that you would like to get the gas to keep you from being nervous and relax more. You also say that you have required laughing gas in the past. The Plan denied your request. The Plan says nitrous oxide is not a covered benefit.  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.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the file does not include documentation to indicate there is an existing infection, previous failure of local anesthesia, or situational anxiety.     Therefore, we decided that the Plan does not have to pay for the nitrous oxide (D9230) provided on November 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that a SNF stay would help you achieve a safe return home. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 24, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment.      Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aranesp (J0881).  You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not meet Part B coverage criteria for the requested 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 Aranesp. Our reviewer says that Aranesp (J0881) is not medically reasonable and necessary. Our physician reviewer found the case file does not contain documentation of trial and failure of Retacrit or Procrit (Epoetin alfa). Our reviewer also found that the documentation does not support that Retacrit or Procrit (Epoetin alfa) would likely be less effective, and/or would likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve provide coverage moderate sedation with injections for
the enrollee.
You asked the Plan to pre-approve injections and moderate sedation. The Plan approved the injections but
denied the sedation. Maximus partially overturned the Plans denial stating the injections were approved and the
sedation was denied. The Plan requested a reopen and stated that the injections had been approved by the Plan
prior to the original decision.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for moderate sedation. 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 this request. Our physician reviewer found the
record does not establish the medical necessity or reasonableness, as defined by Medicare rules, of the need for
monitored anesthesia care services during these injections.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of moderate sedation were not met. Therefore, we decided that the Plan does not
have to pre-approve provide coverage for moderate sedation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for Tempus solid tumor testing provided on April 8, 2021.
You asked the Plan to pay for these services. You say that this testing was medically necessary. 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 we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Tempus solid
tumor testing. Our Physician Reviewer determined that the enrollee has Merkel cell carcinoma
diagnosed March 8, 2021. The role of adjuvant treatment for locally advanced/node positive Merkel cell cancer
is the ongoing subject of clinical trials. Molecular profiling of tumors helps aid in determining eligibility based
on molecular profiling and can identify markers for later lines to therapy. NCCN Guidelines for Merkel cell
strongly recommends enrollment in a clinical trial when available. The use of molecular profiling, such as with
Tempus, was reasonable and medically necessary.
The Plan has requested a reopen and argues Physician Reviewer erred in using Local coverage Determination
LCD L3500 without using the referenced Local Coverage Article A56199 to determine if the requested
services were medically necessary.
Our Medical Director has determined that the Plan is correct in this case. The medical records show the
enrollee is a 73-year-old man with a diagnosis of Merkel cell carcinoma of the nose. The Tempus xT solid
tumor gene panel is a 596 gene panel focused on actionable mutations by DNA sequencing. There is
insufficient evidence that Tempus xT solid tumor gene panel testing is reasonably expected to impact the
treatment and outcome in this enrollee with Merkel cell carcinoma of the nose. Medicare coverage criteria are
not 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for Tempus solid tumor testing provided to the enrollee on April 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that this drug 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). Our Physician Reviewer determined that Keytruda has activity in bonepredominant,
hormone-refractory prostate cancer, status post endocrine therapy and Taxotere. The medication
was determined to be medically necessary. The Plan requested a reopen and stated that Keytruda is only FDAapproved
for use in castrate-resistant prostate cancer, that has progressed despite first-line treatments, is
unresectable and metastatic, and have either high microsatellite instability (MSI), mismatch repair (MMR), or
high tumor mutation burden (TMB). The medical records show the enrollee is a 66-year-old man with a
diagnosis of prostate cancer which is metastatic to bone. Medical records show that the cancer is microsatellite
instability stable, with no loss of nuclear expression of MMR proteins, and is not mismatch repair deficient. It
should be noted the enrollee has refused genetic testing.
Our Medical Director has determined that the Plan is correct in this case. The Physician Reviewer's
determination was based on the Open-label Phase II KEYNOTE-199 study published in the Journal of Clinical
Oncology, 2020 Feb 10; 38(5): 395-405. This is a phase II study that lacked randomization, lacked a control
arm, and had relatively short follow-up. The documentation is insufficient to support that Keytruda is medically
reasonable and necessary for the enrollee 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total knee arthroplasty.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says optical medical management has not been tried and failed.  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 is being treated for pain in both knees, and primary osteoarthritis in the right and left knees. Her pain has been worsening. There is decreased range of motion. X-rays corroborate severe osteoarthritis. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. The cortisone injections were from 2015, 2016, and 2017. The therapy notes provided did not document when it was trialed. Detailed documentation is not evident regarding a trial and failure of any viscosupplementation injections. Large-scale, long-term peer-reviewed literature does not support total knee arthroplasty in the absence of comprehensive conservative treatment trials and with a co-morbidity of obesity.  A detailed of attempted weight loss is not evident. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for knee arthroplasty is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the inpatient hospital care provided from September 4, 2020, through September 6, 2020, and billed with principal diagnosis code N17.9 and secondary diagnosis code E86.0.  You asked the Plan to pay for the inpatient hospital care as originally billed. You say that the inpatient hospital care has been billed correctly based on the medical records. The Plan denied your request. The Plan says that the documentation supports switching the principal and secondary diagnosis codes.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with principal diagnosis code, N17.9, defined as acute kidney injury and the secondary diagnosis code, E86.0, defined as dehydration. 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 pay for the inpatient hospital care as billed. Our reviewer says that the documentation supports the original billed diagnosis codes. Our physician reviewer found the enrollee was a then 73-year-old man with a history of lymphoma, who presented to the hospital on September 4, 2020, with fatigue, weakness, and abdominal discomfort. The enrollee reported fever and chills. Vital signs were notable for hypotension. A generalized rash was present. Laboratory studies were notable for leukocytosis, and elevated BUN and creatinine. The clinical impressions in the Emergency Department were hypotension due to hypovolemia, dehydration, fever, and acute kidney injury. In the admission History and Physical, it is documented that the enrollee was diagnosed with severe sepsis with septic shock and organ failure, and acute renal failure in the setting of sepsis and septic shock. Per coding guidelines, the principal diagnosis would be the condition which led to the hospital inpatient admission. The clinical documentation does not support the Plan's assertion that the enrollee was admitted to the hospital for a principal diagnosis of dehydration. The hospital care was correctly billed with a principal diagnosis code of N17.9 and secondary diagnosis code of E86.0.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the inpatient hospital care provided from September 4, 2020, through September 6, 2020, and billed with principal diagnosis code N17.9 and secondary diagnosis code E86.0.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tacrolimus capsules.  You asked the Plan to pre-approve Tacrolimus. You say that this medication is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. Maximus was able to confirm that you were not enrolled in Medicare Part A when you received the related transplant. 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 Tacrolimus capsules.   Benefits for Tacrolimus 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 LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states the services the enrollee's needs could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.  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 enrollee was admitted with respiratory failure secondary to resumed bacterial or aspiration pneumonia. The record indicates that the enrollee is improving but still requires 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 they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.  The requested service cannot be recommended.  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: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pay for the chiropractic services. We decided that the Plan does not have to pay for the infrared therapy services.   You asked the Plan to pay for the chiropractic services. You say that you are requesting reimbursement of the chiropractic services you paid out of pocket for. The Plan says that the services rendered are not covered by Medicare.  We decided that the Plan has to pay for the office visit, diagnostic and therapeutic services.   The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in function. The health Plan offers additional chiropractic benefits that exceeds Medicare. For that reason, the Plan's coverage rules apply in this case.   The Plan's contract on page 37 specifically says that additional covered chiropractic benefits include evaluation and management services, spine x-rays and chiropractic radiology services and chiropractic physical therapy visits. Based on this information, we decided that Medicare rules for coverage of the chiropractic services have been met Therefore, we decided that the Plan has to pay for the office visit, diagnostic and therapeutic services.   We also decided that the Plan does not have to pay for the infrared therapy services.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  Infrared therapy is specifically excluded from Medicare coverage. Based on this information, we decided that Medicare rules for coverage of the infrared therapy services have not been met Therefore, we decided that the Plan does not have to pay for the infrared therapy services.  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.