Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for date of service February 24, 
2022 to March 3, 2022. 
 
You asked the Plan to pay for procedure code S9502. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9502 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9502 billed for date of service February 24, 2022 to March 3, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. 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. 
 
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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. 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 
alternative. 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria for IRF care were not met. Maximus overturned the Plans denial stating IRF care would be beneficial and a safer environment for the enrollee. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes the enrollee's ability to participate in intensive therapy was limited by weakness and enrollee did not require treatment with a rehabilitation physician at least 3 days per week.
The Plan is correct in this case. 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.
Based on the medical records provided, the criteria required for the enrollee to be able to participate in an intensive therapy program were not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary for the enrollee. 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 coverage criteria. The Plan states the reviewer did not consider the enrollee's ability to
participate in intensive therapy was described as limited by weakness and fatigue per the hospital physical
therapist, and that the member did not require physician supervision by a rehabilitation physician at least 3 days
per week after this hip surgery.
The Plan is correct in this case. 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.
The medical records do not show that at the time of the appeal, the enrollee was able to actively participate in
an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of
at least three hours of therapy per day at least five days per week. Medicare rules for coverage of IRF care were
not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to provide coverage for therapeutic facet joint injections for the enrollee.

You asked the Plan to provide coverage for this service. You say that at the time of the appeal, the requested treatment was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan stated that Maximus did not apply the correct criteria. The Plan notes that several requests were made to the providers office to provide additional medical records to support the services requested. Those requests were not responded to. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers request services correctly and when necessary, provide medical records to support the services appeal. The medical records provided do not clearly indicate all the required coverage criteria were met for the requested injections at the time of the appeal.  Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to provide coverage for therapeutic facet joint injections for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial stating the admission could be beneficial. The Plan requested a reopen and stated that Maximus did not apply or possibly understand the required criteria.
The Plan is correct in this case. 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. Whether or not you would benefit from IRF admission is not of issue, as the rules are clear that you must meet the required criteria prior to admission and have the ability to participate in an intensive therapy program.
Based on the medical records provided, at the time of the appeal, you did not meet this criterion. 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 provide coverage for 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that at the time of the appeal IRF admission was medically necessary. The Plan denied your request. The Plan says at the time of the appeal, all of the required 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.
The Plan is correct in this case. 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. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week.
The medical records provided at the time of the appeal do not show that you met all the required criteria for coverage of this admission due to issues with fracture pain limiting your ability to fully participate in an intense rehabilitative therapy program. 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 provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission 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.
The Plan is correct in this case. 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. Based on the medical records provided, the enrollee did not meet all the required criteria for IRF admission. Whether or not the admission would be beneficial was not of issue as enrollees must meet the required criteria and have to ability to actively participate in an intensive rehabilitation program.
Medicare rules for coverage of IRF care were not met at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a prosthetic leg to include the flex walk system or advance foot feature.
You asked the Plan to provide coverage for this request. You say that the requested prosthetics are medically necessary. The Plan denied your request. The Plan says based on the records provided, the 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. The Plan notes that the records submitted by the therapist indicate you are a limited community ambulator and considered to be at a K2 functional level.
This is inconsistent with the information provided by the forms submitted by the prosthetist and it is clear the required criteria were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires enrollees to be at a K3 level of ambulation for the flex walk system or advanced foot feature to be approved. Based on the actual medical record provided, you are a K2 level ambulator. The information provided by the prosthetist is inconsistent and cannot be verified by the medical records. Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not have to provide coverage for a prosthetic leg to include the flex walk system or advance foot feature.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for BRCA testing.
You asked the Plan to provide coverage for BRCA testing. You say that at the time of the appeal this testing
was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not
met. Maximus stated the regulations used by the Plan retired on August 20, 2022 and should not apply. The
Plan requested a reopen and stated the appeal began on August 3, 2022, prior to the regulation retiring.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests
are not covered. The rules state specific criteria are required for coverage of BRCA testing. Based on the
medical records provided, BRCA testing, was requested solely for screening purposes. All the required
Medicare coverage criteria were not met. Your diagnosis was for pre-malignant skin cancer. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to provide
coverage for BRCA testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary for the enrollee. 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 noted that The Maximus reviewer did not consider that this enrollee's ability to participate in intensive therapy was limited by fatigue and that the enrollee did not require physician supervision by a rehabilitation physician at least 3 days per week.
The Plan is correct in this case. 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.
Based on the medical records provided, while an IRF admission may have been considered beneficial, the enrollee did not meet all the required Medicare criteria at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for parenteral nutrition for the enrollee.
You asked the Plan to provide coverage for parenteral nutrition. You say that at the time of the appeal
parenteral nutrition was medically necessary for the enrollee. The Plan denied your request. The Plan says the
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. The Plan notes the medical records show the
enrollee's malnourishment is not due to a clinical malabsorptive state and the enrollee can take food by mouth.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for parenteral nutrition. Based on the medical records, the enrollee did not meet those criteria at the time of the
original appeal. Therefore, we decided that the Plan does not have to provide coverage for parenteral nutrition
for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission 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. The Plan notes the Maximus reviewer did not consider your ability to participate in intensive therapy was limited by weakness, debility, hypotension, and dizziness. It could not be reasonably expected that you could actively participate in, and benefit significantly from, the intensive rehabilitation therapy program of an IRF
The Plan is correct in this case. 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.
Based on the medical records provided, while an IRF admission may have been beneficial, the required Medicare criteria were not met due to the inability to fully participate in an intensive rehabilitation program. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene analysis provided to the enrollee on June 14, 2021.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan
states these services were billed with Place of Service (POS) 81 for an Independent Laboratory. This is a
laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's
office. Medicare rules state that if an independent lab bills for services, the place where the sample was taken is
reported as the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81"
as place of service. The rules say that for all services (with two (2) exceptions), the POS code to be used by the
physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face
service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which
case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face
service takes place. The testing was performed on a tissue specimen collected. There is no documentation 
that the sample was taken in the laboratory setting. The billing is not supported by clinical documentation. 
The denial is upheld for improper coding and billing and is not based on clinical criteria for medical necessity.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case this claim
created a billing error due to the POS code reported. Medicare billing criteria were not met. Therefore, we
decided that the Plan does not have to pay for gene analysis provided to the enrollee on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 8, 2022.
You asked the Plan to pay for this claim as billed. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating the testing was medically appropriate. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim contained billing errors.
The Plan notes this was an administrative determination for coding and is not based on clinical criteria for medical necessity. The enrollee had molecular cancer genomics (CGx) testing on March 8, 2022. Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. If one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. If no code accurately describes the procedure performed, the laboratory may report code 81479 (Unlisted molecular pathology procedure) with one unit of service. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the enrollee using the results in the management of the specific medical problem. If a single procedure is performed, only one code with one unit of service may be reported for the procedure.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as billed due to the number of units and codes billed for this type of testing. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 18, 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 the Medicare billing criteria were not met.
Maximus overturned the Plans denial stating the services were medically necessary. The Plan requested a reopen and stated the issue was not medical necessity. The Plan stated the issue was with the dates of service reported. The Plan states the records submitted show that a specimen was collected on October 21, 2021. There is no documentation of molecular pathology testing performed on the date billed of January 18, 2022. The Plan further states the required DEXZ Code was not provided.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes as well as the appropriate dates of service. In this case, this claim could not be paid as billed due to an inconsistency with the dates of service and date of specimen collection reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission 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 coverage criteria. The Plan noted that the medical records stated that your ability to participate in therapy was described as limited due to confusion, weakness, and fatigue. It was not expected that you would require rehabilitation physician services at least 3 days per week.
The Plan is correct in this case. 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. Based on the medical records provided, you did not meet the required Medicare coverage criteria for IRF admission at the time of the appeal.
Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.