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

 
We decided that the Plan does not have to pre-approve Keytruda, Cyramza, and Diphenhydramine. 
 
You asked the Plan to pre-approve Keytruda, Cyramza, and Diphenhydramine. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda, Cyramza, and 
Diphenhydramine. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found in this case, the record indicates that the enrollee has a diagnosis of metastatic non-small cell lung cancer 
(adenocarcinoma) that is PDL-1 expression less than 1 and negative for actionable mutations. The record 
indicates that the enrollee has experienced disease progression on Keytruda. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 
The elements of the coverage criteria 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 Keytruda, Cyramza, and Diphenhydramine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Keytruda, Cyramza, and Diphenhydramine.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 
You asked the Plan to pre-approve Ocrevus. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Ocrevus. Our reviewer says that the 
requirements for coverage of Ocrevus have not been met. Our physician reviewer found the plan requires a trial 
of Kesimpta before it will approve Ocrevus. In this case, the enrolle has not tried and failed the required drugs. 
There is no documentation provided indicating that the required drugs would likely be less effective or 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 Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse BMP Allograft and bone marrow 
aspirate. 
 
You asked the Plan to pre-approve Medtronic Infuse BMP Allograft and bone marrow aspirate. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 Medtronic Infuse BMP Allograft and 
bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested Medtronic Infuse BMP allograft, in this case, 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 Medtronic Infuse BMP Allograft and bone marrow aspirate have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Medtronic Infuse BMP Allograft and bone 
marrow aspirate.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 14, 
2022 to June 12, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not medically necessary. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee no longer qualified for SNF coverage. The enrollee did not have 
documented skilled nursing or skilled therapy needs. Daily skilled services were not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs could, as 
a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 14, 2022 to June 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing provided to the enrollee on November 23, 
2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this testing is not separately billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing provided to the enrollee on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 20, 2022, billed with 
codes 81220, 81329, and 81420. 
 
You asked the Plan to pay for the testing. You say that the testing was medically necessary The Plan denied 
your request. The Plan says the billed screening tests are excluded from coverage. 
 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 tests at issue in this appeal, codes 81220, 81329, and 81420, were 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 genetic testing provided on May 20, 2022, billed with codes 81220, 81329, and 81420.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an Optimizer Smart device 
(0408T). 
 
You asked the Plan to pre-approve placement of an Optimizer Smart device. You say that the requested service 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 placement of an Optimizer Smart 
device. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that cardiac contractility modulation remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of placement of an Optimizer Smart device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve surgical placement of an Optimizer Smart device (0408T).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from February 24, 2022, to March 
17, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like payment to be approved 
for this claim. The Plan denied your request. The Plan says that this claim was denied due to missing medical 
records not received. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says 
that the home health services were medically reasonable and necessary for the enrollee. Our physician reviewer 
found there is documentation that skilled speech therapy services were required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a 
maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Records 
document the enrollee was homebound, had deficits in speech and comprehension, and had expressive aphasia 
after a stroke that was treated with a series of speech therapy interventions and home exercises. Our reviewer 
also found that the records document signed reports indicating physician review, approval of the services 
provided, and certification of their medical necessity.  
 
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 home health services have been met. Therefore, we decided that the Plan has 
to pay for the home health services provided from February 24, 2022, to March 17, 2022.  
 
  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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services on 
February 3, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility services. You say that you would like to 
appeal the cost share. The 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 $184 copayment per day for days 21-100 for skilled nursing facility services.  
 
The enrollee has been asked to pay a $184 copayment per day for days 21-100 for skilled nursing facility 
services. This item/service falls within the Skilled nursing facility (SNF) care 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 skilled nursing facility services on February 3, 2022, to February 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services rendered on March 29, 2022. 
 
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 procedure codes 64636-LT and 64636-RT are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64636 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 64636 is not supported in the medical record. Specifically, the add-on code was not 
billed with a required primary procedure code. 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 the 
pain management services rendered on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visits provided on June 3, 
2022, to June 17, 2022. 
 
You asked the Plan to waive the copayment for emergency room visits. You say that you should not be charged 
for these services because your symptoms were not addressed. The 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). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency services.  
 
You have been asked to pay a $90 copayment for each of two emergency room visits. These services fall 
within the emergency services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency 
room visits provided on June 3, 2022, to June 17, 2022.   
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve other accessories for a power wheelchair (ability drive interface, 
Permobil/rnet alternative drive port for ability drive). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that these items are experimental and investigational. 
 
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 accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has progressive multiple sclerosis with the inability to move her upper and lower 
extremities as well as upper and lower extremity spasticity. She is dependent upon a group 3 power wheelchair 
for mobility and performing her daily activities and requires power elevating leg rests and power tilt and recline 
for management of her spasticity and positioning needs. The documentation indicates that the patient does not 
have the dexterity required to operate the power wheelchair and its power components with her upper or lower 
limbs. She also does not have the head and neck strength and coordination to control it via her head or chin. 
Therefore, she is left with the option to control it via the ability drive interface with eye control. It is not for the 
convenience of the patient and appropriate for her medical 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 the accessories have been met. Therefore, we decided that the Plan has to pre-
approve other accessories for a power wheelchair (ability drive interface, Permobil/rnet alternative drive port 
for ability drive).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99497 billed for date of service July 11, 2021. 
 
You asked the Plan to pay for code 99497. You say that these codes are separately payable. The Plan denied 
your request. The Plan says that payment for code 99497 is bundled into code 99223. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 99497 is a column II code to column I code 99223; however, code 
99223 was billed with a modifier (modifier 25 to be precise).  The Plan has failed to discuss why this modifier 
did not 'unbundle' code 99497.  The Plan has failed to contend that this modifier is not supported in the record.  
In fact, in its narrative, the Plan erroneously notes that no modifier was billed, which is contradicted by the 
Plan's own Remittance Advice, which lists the 25 modifier.  The burden is on the Plan to support its denial, and 
it has failed to do so in this case. Based on this information, we decided that Medicare rules for coverage of 
code 99497 have been met. Therefore, we decided that the Plan has to pay for code 99497 billed for date of 
service July 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the records support this admission. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is not shown to have a significant decline in function. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 14, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that respiratory panels with more than five respiratory 
pathogens performed in the Part B outpatient setting are not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that more than five pathogens were tested. Therefore, 
we decided that the Plan does not have to pay for the laboratory services rendered on December 14, 2021.