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

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 25, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the service should be reprocessed and paid. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller
harness (E2313) and electronic connection (E2311).
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan
denied your request. The Plan says that there is no need to control the power options through the joystick.
Our Medical director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, expandable controller harness and electronic connection. Our Medical Director states that the
documentation supports that you would be able to control the power options with their own switches. The
documentation does not support that the expandable control system was medically reasonable and necessary for
this enrollee. Our physician reviewer found that your 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 an expandable controller (E2377), expandable controller harness (E2313) and electronic
connection (E2311).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided the Plan has to pay for inpatient hospital care provided from June 23, 2021, through June 28, 2021.
You asked the Plan to pay for these services. You say that these services should be paid as billed. The Plan
denied your request. The Plan says that Medicare coverage criteria were not met. Maximus overturned the
Plans decision. The Plan requested a reopen and stated Maximus did not address this appeal based on the
readmission rules.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for readmission to the
hospital. The Maximus Physician Reviewer determined that that the criteria for inpatient payment were met in
this case. The reviewer found that the enrollee had been discharged on June 19, 2021, but returned to the
emergency department on June 20, 2021, with agitation and delirium. She was admitted and continued on
intravenous antibiotics. The Plan requested a reopen and stated that their administrative determination for noncoverage
was based on a readmission due lack of medical records; this was not a medical necessity
determination of the hospitalization. The Plan stated no documentation, other than orders, were provided for
the preceding admission starting on June 11, 2021. Therefore, completeness of care, stability at discharge, and
adequacy of discharge planning for that initial hospitalization cannot be determined. However, additional
medical records were submitted directly to Maximus for review by the provider which is their right to do when
the IRE is reviewing the appeal. The records show the enrollee is a 70-year-old woman with a history of
diabetes, hypertension, dementia, and pulmonary embolism, who was originally admitted to the hospital on
June 11, 2021, after being found on the floor with altered mental status. The diagnosis was an acute infarct in
the right cerebellar hemisphere. Listeria meningitis meningoencephalitis could not be ruled out, and a 21-day
course of IV amoxicillin was planned. The enrollee's neurologic function improved. On June 19, 2021, the
enrollee was in no acute distress. The enrollee was noted to be "back to baseline." The enrollee was then
readmitted to the hospital on June 23, 2021, with altered mental status, hallucinations, and combative behavior
over the previous 12 hours. IV antibiotics were continued.
The rules say readmissions should be denied if the readmission was medically unnecessary; if the readmission
resulted from a premature discharge from the same hospital; or if the readmission was a result of circumvention
of PPS by the same hospital. The documentation supports that readmission was medically necessary for the
enrollee in this case and was not a result of a premature discharge from the same hospital.
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 been met. Therefore, we decided that the Plan has to pay for
inpatient hospital care provided from June 23, 2021, through June 28, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vabysmo, 6mg every 6 weeks. 
 
You asked the Plan to pre-approve Vabysmo, 6mg every 6 weeks. You say that this dosage plan is for enrollees 
who were treatment naive. You say that the enrollee has been receiving this drug at a 6-week interval with the 
goal of being able to increase the treatment interval while preventing leakage. The Plan denied your request. 
The Plan says that the requested dose plan is not approved by the FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Vabysmo, 6mg every 6 weeks. Our 
reviewer says that the requested dose of Vabysmo is medically necessary. Our physician reviewer found the 
Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition. The 
reviewer found that the enrollee is already receiving intravitreal injections. Therefore, the reviewer found that 
the requested drug, as prescribed, is medically necessary and reasonable, as defined by Medicare rules, for the 
enrollee's clinical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo, 6mg every 6 weeks have been met. Therefore, we decided that the 
Plan has to pre-approve Vabysmo, 6mg every 6 weeks.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (97015), and administration (90471) provided on October 19, 2021. 
 
You asked the Plan to pay for the immunization. You say that this service is payable. The Plan denied your 
request. The Plan says the immunization provided is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (97015), and administration (90471) provided on October 19, 2021.  
 Benefits for the immunization 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot inserts (L3000 x 2) provided on November 18, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the foot inserts. You say that the items should be covered. The Plan denied your 
request. The Plan says prior authorization was not obtained.  
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 provider in this case is not a network provider with the Plan. 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. Additionally, 
orthopedic shoes and other supportive devices for the feet generally are not covered. Therefore, we decided that 
the Plan does not have to pay for the foot inserts (L3000 x 2) provided on November 18, 2021, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you have pain when you are walking, and you 
cannot walk far distances. The Plan denied your request. The Plan says you do not meet criteria for the 
requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a three-wheel walker. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and electrocardiogram (EKG) 
(93000) provided on July 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management services. You say that you needed to find a new 
cardiologist. You say that yours moved away. You also say that you found this provider in the plan's provider 
directory. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit (99204) and electrocardiogram 
(EKG) (93000) provided on July 15, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, 
emergency transport (A0429) and ground mileage (A0425) provided on June 24, 2022. 
 
 
You asked the Plan to waive the copayment for the emergency ambulance transport and ground mileage. You 
say that the enrollee cannot afford the cost of this service. Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment for each one-way Medicare-covered ground transportation service. 
 The enrollee has been asked to pay a $300 copayment for the emergency ambulance transport and ground 
mileage. This item/service falls within Ambulance Services benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) and 
ground mileage (A0425) provided on June 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided from February 15, 2021, 
to March 13, 2021. 
 
You asked the Plan to pay for home health care services. The Plan denied your request. The Plan says the non-
contracted provider did not submit the RAP claim for date of service February 15, 2021 to March 13, 2021 
until February 16, 2022. 
 The Plan follows Medicare rules. The rules say that an RAP must be submitted within 5 days of the start of 
care date for home health services. RAPs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care. 
 
In this case, the start of care date is February 15, 2021. The RAP was not received by the Plan until  
February 16, 2022. As more than 30 days passed between the timely filing date and the RAP receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
care services provided from February 15, 2021, to March 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, Orthovisc or Supartz FX. 
 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 Gelsyn-3. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. 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 
alternatives. 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 25, 2022.
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 you need IRF care. The Plan denied your request. The Plan says that rules for IRF care have not been met.
Our Medical director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states the documentation does not support that the clinical documentation does not support that you required and would tolerate at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services, and would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Puraply xt (Q4197) provided from July 6, 2022, to July 11, 
2022. 
 
You asked the Plan to pay for the wound care. You say that despite the wound care and all interventional 
measures in place, the enrollee's ulcers have failed to improve. You also say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the Puraply xt is not covered by the Plan or 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wound care have not been met. Therefore, we decided that the Plan does not have to pay for 
Puraply xt (Q4197) provided from July 6, 2022, to July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on July 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the service should be covered. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 hospital outpatient clinic visit (G0463) provided on July 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for imaging services provided to the enrollee on January 11, 2022.
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 these services were previously billed by the same group. Maximus overturned the Plans denial stating the services were medically necessary. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the services were inappropriately billed a second time. The Plan provided documentation to show this service was previously paid to the same physician group.
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 billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on January 11, 2022.