Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on August 26, 2022.
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. After the decision was made, an error was found, and the case was reopened.
Our Medical Director looked at the case file. At issue is coverage for physical therapy (PT) services provided on 8/26/2022 to an enrollee with temporomandibular joint (TMJ) disorder. The enrollee was a then 71-year-old woman with listed diagnoses of Muscle weakness (generalized), Right temporomandibular joint disorder, unspecified, and Radiculopathy, occipito-atlanto-axial region. The enrollee was referred to PT by a dentist. The initial PT evaluation took place on April 13, 2022, at which time the enrollee reported right TMJ pain that had gradually worsened over the previous few months. The treatment plan included soft tissue mobilization and stretching, dry needling, a progressive program of therapeutic exercise, a progressive program of neuromuscular re-education, and therapeutic modalities. One of the PT goals was, "The patient will be independent in a home exercise program in order to maintain gains made in therapy and prevent future problems." The plan was for a frequency and duration of "Initially 1 - 2 times weekly, decreasing in frequency as indicated by patient progression, for 15 sessions." Daily notes dated August 26, 2022, state at that time, manual therapy and therapeutic exercise were performed. The plan was, "Continue the current plan of care and progress program as appropriate." The source of the enrollee's TMJ symptoms is not clear from the PT documentation. Consequently, it cannot be determined that the symptoms are primarily medical in nature. Patients with TMJ disorder, particularly those with a prominent musculoskeletal component, or cervical or shoulder symptoms, are often referred for PT evaluation and treatment. However, there is a lack of high-quality data demonstrating the overall efficacy of physical therapy in the treatment of the disorder. In this case, the enrollee had previously been treated with outpatient therapies beginning in April of 2022. It is reasonably expected that she should have been independent with a home exercise program by August of 2022. There was no documentation of any recent injury or a decline in function. The additional therapy services were not of appropriate duration and frequency for treatment of the enrollee's condition, and therefore were 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee on August 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone provided on March 9, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone. You say that you have been a 
Substance Abuse and Mental Health Services Administration (SAMHSA) certified provider since 2004. The 
Plan denied your request. The Plan says that the charge for the drug and its administration must be billed by the 
Medicare-enrolled Opioid Treatment Program. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for medication assisted 
treatment, methadone provided on March 9, 2023.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 01, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on February 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF System. 
 
You asked the Plan to pre-approve the CardioMEMS HF System. You say that the CardioMEMS HF System 
would help with consistent monitoring of pulmonary artery (PA) pressures and thus help with diuretic therapy. 
You say that this would decrease incidence of re-hospitalization. The Plan denied your request. The Plan says 
the CardioMEMS device, at this point, should only be approved for patients enrolled in a clinical trial. There is 
no indication that this patient is enrolled in a clinical trial of the device. 
 
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 the CardioMEMS HF System. Our 
reviewer says that the requested CardioMEMS HF System is not considered medically reasonable and 
necessary. Our physician reviewer found that the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. 
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS HF System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 19, 2023, billed 
with procedure codes 77336 and 77385. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 1, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the practitioner services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
January 19, 2023, billed with procedure codes 77336 and 77385.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says your benefit for SNF care has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 01, 2023, to 
August 1, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eight units of procedure code 87798 rendered on January 26, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted does not specifically list additional individual bacterial and/or viral 
targets tested on the billed date of service separately from the infectious respiratory panel. 
 
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 87798 is "Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism."
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of eight units of CPT 87798, as the organisms tested have been covered in the approved CPT 
codes with the respiratory panel codes. The documentation cannot verify the use of 8 units of CPT 87798. 
 
We looked at this coder'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 pay for eight units of procedure code 87798 rendered on January 26, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 21, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says 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 Plan says that the Plan has also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 13, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says per the 
members benefits office visits are covered by Medicare, however the provider is not under contract with the 
health Plan and is not certified with 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 pay for 
physician's services provided on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies coded as A6196, A6199, A6212 
provided January 18, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that this denial will prevent the enrollee from 
receiving medically necessary treatment for the wound care supplies needed. The Plan denied your request. The 
Plan says these services/supplies are not separately reimbursable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies were used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for the wound care supplies coded as A6196, A6199, A6212 provided January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on January 6, 2023.
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. After the original decision was made it was determined overturn was done in error and case was reopened.
Our Medical Director looked at the case file. At issue is coverage for physical therapy (PT) services provided on January 6, 2023, to an enrollee with temporomandibular joint (TMJ) disorder. The enrollee was a then 71-year-old woman with listed diagnoses of Muscle weakness (generalized), Right temporomandibular joint disorder, unspecified, and Radiculopathy, occipito-atlanto-axial region. The enrollee was referred to PT by a dentist. The initial PT evaluation took place on April 13, 2022, at which time the enrollee reported right TMJ pain that had gradually worsened over the previous few months. The treatment plan included soft tissue mobilization and stretching, dry needling, a progressive program of therapeutic exercise, a progressive program of neuromuscular re-education, and therapeutic modalities. One of the PT goals was, "The patient will be independent in a home exercise program in order to maintain gains made in therapy and prevent future problems." The plan was for a frequency and duration of "Initially 1 - 2 times weekly, decreasing in frequency as indicated by patient progression, for 15 sessions." The case file also contains a daily note which states the plan was to continue the current plan of care and progress program as appropriate. The source of the enrollee's TMJ symptoms is not clear from the PT documentation. Consequently, it cannot be determined that the symptoms are primarily medical in nature. Patients with TMJ disorder, particularly those with a prominent musculoskeletal component, or cervical or shoulder symptoms, are often referred for PT evaluation and treatment. However, there is a lack of high-quality data demonstrating the overall efficacy of physical therapy in the treatment of the disorder. In this case, the enrollee had previously been treated with outpatient therapies beginning in April of 2022. It is reasonably expected that she should have been independent with a home exercise program by January of 2023. There was no documentation of any recent injury or a decline in function. The additional therapy services were not of appropriate duration and frequency for treatment of the enrollee's condition, and therefore were 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided to the enrollee on January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel testing (81455) provided February 
20, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says Based on the Medicare guidelines the request for a genetic panel performed on 
February 20, 2023, does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The clinical information submitted does not indicate that the enrollee 
has advanced, refractory, metastatic or recurrent Stage III or IV cancer. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus Gene Panel testing (81455) provided February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level of injection rendered on December 5, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says two levels were approved by the plan, and the third remains denied. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the utilization criteria limits the number of levels treated to 2 levels per session. Therefore, the third 
level is deemed not medically reasonable and 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 pay for a third level of injection rendered on December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 19, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 13, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 13, 2022.