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

 
We decided that the Plan does not have to pre-approve Zirabev, Ondansetron, Dexamethasone, Famotidine and 
Diphenhydramine for the enrollee. 
 
You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary. The Plan 
denied your request. The Plan says that these drugs are not being used for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 these drugs. Our reviewer says that 
these drugs are not medically reasonable and necessary. The requested use of Zirabev, Ondansetron, 
Dexamethasone, Famotidine and Diphenhydramine is not FDA-approved for the enrollees diagnosis. The use 
of these drugs is supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. Our physician reviewer found that the enrollee's 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 drugs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zirabev, Ondansetron, Dexamethasone, Famotidine and Diphenhydramine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on 
September 28, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code 
cannot be separately billed. 
 
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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. We find that CPT code 99442 was billed with diagnosis code C25.0, malignant neoplasm of the head of the 
pancreas. The records show that the enrollee received evaluation and management services within the previous 
7 days for the same condition. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for physician's services provided on July 26, 2021. 
 
You asked the Plan to reimburse you for the physician's services. The Plan denied your request. The Plan says 
the service obtained was rendered by a provider who does not accept Medicare assignment. The provider has 
opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
physician's services provided on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have excruciating pain on your feet. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenomics (PGx) panel provided 
on April 1, 2021. 
 
You asked the Plan to pay for the PGx panel. You say that this cardiomyopathy COVID-19 panel was 
medically necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of PGx testing requires that the clinical 
record clearly document the use or intent to prescribe a drug that has known drug-gene interactions that require 
a PGx test to be ordered to define the safe use of that drug in that patient.  
 
We looked at the file and Medicare rules. The appeal letter in this case appears to reference testing other than 
the type of testing provided. The records do not document that there are specific drugs for which safe use must 
be defined for this particular patient. This is an extensive screening panel for the metabolism of multiple drugs. 
Based on this information, we decided that Medicare rules for coverage of the PGx panel have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenomics (PGx) 
panel provided on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for radiofrequency ablation at three levels.
You asked the Plan to provide coverage for radiofrequency ablations at three levels. You say that this treatment
is medically necessary. The Plan denied your request. The Plan says Medicare does not cover the three levels
requested. Maxims partially overturned the Plans denial and approved two of the three levels requested. The
Plan requested a reopen and noted that the Plan approved two of the three levels prior to our decision and that
technically the IREs decision and the Plans was the same.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare covers two levels of
radiofrequency ablation. The Plan approved two levels of treatment and the IRE confirmed that only two levels
of treatment were appropriate. Therefore, we decided that the Plan does not have to provide coverage for
radiofrequency ablation at three levels.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional home health services for the
enrollee.
You asked the Plan to provide coverage for additional home health services. You say that at the time of the
appeal, this care 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
Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for 11 additional
home health physical therapy visits. The Maximus Physician Reviewer determined that the requested services
were medically reasonable and necessary. The Plan requested a reopen and argues that the medical record does
not document the services of a skilled physical therapist beyond December 28, 2021. "The enrollee has already
been educated on a home exercise program. There is no documentation of an active or acute on chronic
condition that would necessitate a new program." The Plan argues that they received a request to appeal the
Home Health Physical Therapy services on December 30, 2021, following the completion of the approved 7
visits. The Plan is correct in this case. The records do not support those 11 additional skilled therapy visits were
required to effectively provide treatment, care, and/or services to improve the enrollee's level of function, or to
establish/perform a maintenance program to maintain the patient's level of function and/or prevent
deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that
the Plan does not have to provide coverage for additional home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for administration charges for the Shingles vaccine you received 
on December 7, 2021, under your medical benefits. 
 
You asked the Plan to pay for administration charges for the Shingles vaccine. You say that you were told you 
would not owe anything if you got the Shingles vaccine in your primary care doctor's office. The Plan denied 
your request. The Plan says administration of the Shingles vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide administration 
charges for the Shingles vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to administration 
charges for the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for administration 
charges for the Shingles vaccine you received on December 7, 2021.  
 
 Benefits for administration charges for the Shingles vaccine 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. 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 Reblozyl. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no documentation that the Reblozyl meets Medicare 
criteria for safe and effective for the enrollee. Reblozyl is indicated for anemia, after erythropoiesis stimulating 
agent failure, requiring 2 or more red blood cell units over 8 weeks with myelodysplastic/myeloproliferative 
neoplasm with ring sideroblasts and thrombocytosis. The enrollee does not meet these criteria based on the 
provided records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on November 29, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the CT scan. You say that you disagree with the denial and would like the plan to 
reconsider payment. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
 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. 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 CT scan provided on November 29, 2021, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multianalyte assay with algorithmic analysis (81599) 
provided on November 15, 2021 by an out-of-network (OON) provider. 
 You asked the Plan to pay for the laboratory services. You say that the requisition form confirms the test was 
ordered by the treating physician with the intent to use the test results to inform treatment decisions. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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. 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. This test is also considered investigative and experimental. 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 multianalyte assay with algorithmic analysis (81599) provided on November 15, 2021 by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on September 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the injections. You say that you would like the claim to be reprocessed for 
payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no referral from an in-network provider or an approved authorization. Also, the service rendered was 
not urgent or emergent. 
 
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. 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 injections provided on September 28, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided 
from November 2, 2021, to November 5, 2021. We also decided that the Plan does not have to waive the 
copayment for an emergency room (ER) visit provided on November 22, 2021. 
 
You asked the Plan to waive the copayments for an outpatient hospital observation and an ER visit. You say 
that you had a routine colonoscopy which resulted in a perforation and were hospitalized. You also say you 
should not bear any financial responsibility for the hospitalization, or the extra emergency room visit. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 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 each in-network outpatient hospital observation visit, including all services received. The Plan 
contract also says that enrollees must pay a $90 copayment for each in and out of network emergency room 
visit. 
 
You have been asked to pay a $90 copayment for outpatient hospital observation from November 2, 2021, to 
November 5, 2021. Outpatient hospital observation falls within the Outpatient Hospital Observation benefit 
category. You have been asked to pay a $90 copayment for an emergency room visit on November 22, 2021. 
An emergency room visit falls within the Emergency Care 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 outpatient hospital observation provided from November 2, 2021, to November 5, 
2021. We also decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on November 22, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit (99204, 99214), an 
electrocardiogram, routine ECG with at least 12 leads (93000), a radiologic examination, chest, 2 views 
(71046), and laboratory services (85025, 80048) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit, an electrocardiogram, routine ECG with at least 12 
leads, a radiologic examination, chest, 2 views, and laboratory services. You say that the patient was referred 
for a surgical consult from her cardiologist. The Plan denied your request. The Plan says in this case, the 
medical record received did not show that the enrollee has an emergent or urgent medical condition, or are in 
need of specialized service. The Plan also says that there are in-network providers within a reasonable distance 
from the enrollee's location that can provide this service/item. 
 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit (99204, 99214), an electrocardiogram, routine ECG with at least 12 leads (93000), a 
radiologic examination, chest, 2 views (71046), and laboratory services (85025, 80048) to be provided by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and skilled 
nursing services (G0299). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of decline in your physical or mental condition, and you have not 
had any emergency room or inpatient visits in the last year. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
doesnt support that you require skilled nursing services to provide treatment that is medically necessary. You do not require skilled nursing services to effectively provide treatment, care, and/or services in order to 
improve your condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration.  You have been medically stable without any recent exacerbations of chronic medical problems 
or hospitalizations. You do not require the services of a home health aide as he has homemaker services and is 
independent with self-care tasks. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide (HHA) services (G0156) and skilled nursing services (G0299).