Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).  You asked the Plan to pre-approve the Dexcom G6 CGM. You say that the Freestyle Libre has been inconsistent in performance and unreliable over time. You say that both you and your doctor are unsure if the item is providing a correct reading. The Plan denied your request. The Plan says there are no clinical notes or evidence that the current item is worn out, broken, or needs repair or replacement.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have a Freestyle Libre CGM. A Freestyle Libre CGM serves the same purpose as the Dexcom G6 CGM. The records show that you received this item on September 10, 2021. The reasonable and useful lifetime of this item has not yet passed. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
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 therapy at home has not been enough to make any true gains. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for encephalopathy and coronavirus. There is ongoing weakness despite home health services. The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.

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 home mechanical ventilator.  You asked the Plan to pre-approve a home mechanical ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a home mechanical ventilator. Our reviewer says that a home mechanical ventilator is not medically reasonable and necessary. You have chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS capability. The record does not indicate that this modality has been trialed and failed or provided a sufficient medical rationale why it would not be appropriate for you to be prescribed this modality. Our physician reviewer found that your condition does not meet Medicare criteria for a home mechanical ventilator.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home mechanical ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee lives alone and needs inpatient rehab to become independent again. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an IRF admission and services.  You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar spine surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Bevacizumab in combination with IV Cisplatin
and Paclitaxel for the enrollee.
You asked the Plan to provide coverage for Bevacizumab in combination with IV Cisplatin and Paclitaxel. You
say that this drug regimen is medically necessary for the enrollee. 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 Bevacizumab in
combination with IV Cisplatin and Paclitaxel. The Maximus Physician Reviewer determined that Bevacizumab
is FDA-approved for the treatment of stage III or IV epithelial ovarian, fallopian tube, or primary peritoneal
cancer following initial surgical resection (in combination with carboplatin and paclitaxel, followed by singleagent
bevacizumab).
The Plan requested a reopen and stated that the request was for IV Cisplatin with Bevacizumab/Paclitaxel. The
Plan states that intravenous Cisplatin with bevacizumab/paclitaxel for stage IIIC high-grade serous
adenocarcinoma of the ovary does not have support in a Medicare-accepted compendia or Medicare accepted
medical journals.
The medical records show the enrollee is a 68-year-old woman with a diagnosis of stage IIIc high-grade serous
ovarian cancer. The enrollee was treated with neoadjuvant chemotherapy, Carboplatin and Paclitaxel, followed
by Paclitaxel weekly and Bevacizumab every 2 weeks, with cytoreductive surgery on June 21, 2021. A
treatment regimen of maintenance Paclitaxel and Bevacizumab, with the addition of Cisplatin every 3 weeks
for 4 cycles, was to begin on August 17, 2021, and was to be followed by maintenance Bevacizumab.
Our Medical Director has concluded that the Plan is correct in this case. There is insufficient evidence to
support the use of Bevacizumab in combination with IV Cisplatin and Paclitaxel, for the management of stage
IIIc high-grade serous ovarian cancer.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Bevacizumab in combination with IV Cisplatin and Paclitaxel have not been
met. Therefore, we decided that the Plan does not have to pre-approve Bevacizumab in combination with IV
Cisplatin and Paclitaxel for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 14, 2022, forward.

You asked the Plan to pre-approve inpatient psychiatric care from February 14, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric care from February 14, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment from February 14, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment from February 14, 2022, forward as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from February 14, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 14, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care (99232) provided on September 30, 2020.

You asked the Plan to pay for the hospital care. You say that this claim is denying in error as a duplicate. The Plan denied your request. The Plan says this is a duplicate claim and has already paid.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. In this case, the Plan has provided evidence of paid claims for a service date September 28, 2020, and a service date of September 30, 2020. The claim that is not processing is for a duplicate of the September 30 claim that appears to have been billed twice. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the hospital care (99232) provided on September 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.  You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says the provider has not shown why the test was ordered.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scan. Our physician reviewer found that in this case, the record indicates that the enrollee has a history of colorectal adenocarcinoma treated with surgery and chemotherapy. The enrollee has had two CT scans in the past several months, including one in December 2021. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this time.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cataract removal surgery (66984) provided on September 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the cataract removal surgery. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 requested provider in this case is not a network provider with the Plan. Although you state the provider in question is in-network, this provider is nowhere to be found on the enrollee's medical records documenting the services rendered. 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 cataract removal surgery (66984) provided on September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) services.

You asked the Plan to pre-approve the LDCT. You say that the clinical documentation provided supports the need for the requested LDCT services. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that LDCT service are covered when specific eligibility criteria have been met. 

We looked at the file and Medicare rules. The records show that the enrollee is 52 years old. Based on this information, we decided that Medicare rules for coverage of the LDCT have not been met. Therefore, we decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 5, 2021, under the
Medicare Benefit.
You asked the Plan to pay for this testing under the Medicare Benefit. You say that these services should be
paid by the Plan. The Plan denied your request. The Plan says this cost share was applied based on your dual
eligibility. Maximus overturned the Plans denial. The Plan requested a reopen and stated this claim was
processed towards your Medicaid benefit. The Plan provided documentation to show that you are Medicaid
eligible and that this claim was submitted to Medicaid for payment. Any concerns regarding the cost share
must be addressed through Medicaid.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information.
Your contract with the Plan clearly says you are a dual eligible member. This claim was submitted to and
processed under your Medicaid benefit. Neither the Plan nor Maximus has the authority to waive this cost share
as we can only review those services applied to your Medicare benefit. Therefore, we decided that the Plan
does not have to pay for drug testing provided on February 5, 2021, under the Medicare Benefit.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87338, 87798 XU, 83520, 82656, 83631, 82274, 87177, 87209, 82705 XU, 89055) provided on September 21, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87338, 87798 XU, 83520, 82656, 83631, 82274, 87177, 87209, 82705 XU, 89055, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on September 21, 2021, and received by the lab on September 23, 2021. Of note, the patient resides in California (CA) and the billing laboratory is located in New Jersey (NJ); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87338, 87798 XU, 83520, 82656, 83631, 82274, 87177, 87209, 82705 XU, 89055) provided on September 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Physical Therapy services (97163, 97112, 97140 and 97110) provided on January 26, 2021, through April 22, 2021.  You asked the Plan to pay for the Physical Therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed per Medicare guidance.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT codes 97163, 97112, 97140 and 97110 are not supported in the medical record. Specifically, this claim was not billed correctly. Providers are required to report line item dates of service per revenue code line for outpatient rehabilitation services. CORFs are also required to report their full range of CORF services by line item date of service. In this case, the claim was billed with a date range and not with individual line items representing the dates of service that the services were rendered.  Based on this information, we decided that Medicare rules for coverage of the Physical Therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the Physical Therapy services (97163, 97112, 97140 and 97110) provided on January 26, 2021, through April 22, 2021.