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

 
We decided that the Plan does not have to pay for the ambulatory surgical center services provided on March 
21, 2023. 
 
You asked the Plan to pay for the ambulatory surgical center services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that the ambulatory surgical center services are not supported in the medical record. Specifically, there 
are no ambulatory surgical centers at the billed servicing location. Based on this information, we decided that 
Medicare rules for coverage of the ambulatory surgical center services have not been met. Therefore, we 
decided that the Plan does not have to pay for the ambulatory surgical center services provided on March 21, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx Biopsy (0037U) provided on May 
2, 2023. 
 
You asked the Plan to pay for the FoundationOne CDx Biopsy. You say that this testing was a medically 
necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has advanced, 
metastatic, recurrent, or refractory cancer. 
 The Plan must follow Medicare rules. Medicare rules say that this testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer.  
 
We looked at the file and Medicare rules. In this case the records do not show that the enrollee has recurrent, 
relapsed, refractory, metastatic, or advanced stages III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the FoundationOne CDx Biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the FoundationOne CDx Biopsy (0037U) provided on May 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says admission to a LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not currently available at 
the facility being offered by the health Plan.   
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this enrollee meets and/or exceeds the 
requirements for LTACH level of care. The Plan denied your request. The Plan says that the enrollee can 
receive the necessary care in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. Documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6402 billed for date of service April 10, 
2023. 
 
You asked the Plan to pay for procedure code A6402. You say that the items at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the billed code is bundled/excluded. 
 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 A6402 has a Status Indicator of P on the Physician Fee Schedule. This means that 
procedure code A6402 is bundled/excluded. Based on this information, we decided that Medicare rules for 
coverage of procedure code A6402 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6402 billed for date of service April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81226, 81291) provided on 
March 24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that this appeal letter is to dispute the determination 
given on the claim. 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. 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 GeneSight Psychotropic test (81226, 81291) 
provided on March 24, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a MyoElectric upper limb prosthesis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is widely recognized that a shoulder disarticulation is one of the most debilitating amputations that 
a patient can suffer, and it is extremely difficult to treat prosthetically with anything but sophisticated, 
externally powered components and control systems. The requested prosthesis and all associated components 
are reasonable and necessary, not least of all because no other medically appropriate alternative exists that can 
actually meet his basic need to have some amount of left side function and bimanual dexterity restored. Even in 
the absence of specific regulations in this area, original Medicare does have a history of covering myoelectric 
upper extremity devices such as this, and it would certainly do so for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve a MyoElectric upper limb prosthesis.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the requested use of this drug combination is not supported. 
 
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 the medication. Our reviewer says that 
that the requested use of Keytruda in combination with carboplatin and paclitaxel is not FDA approved for the 
enrollees diagnosis. Our physician reviewer found that the use of Keytruda is also not supported by one of the 
major drug compendia or by clinical research.  
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 93970 for date of service August 22, 2022, billed to the enrollee under Claim A.
You asked the Plan to pay Claim A. The Plan denied your request. The Plan says this service was previously paid under Claim B. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional claim information.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be duplicates of another claim or claim line are denied. The Plan submitted a copy of the previously paid claim.
There is no evidence presented to support that the billed services were provided twice on the same date. Medicare rules for payment of the appealed claim are not met. Therefore, we decided that the Plan does not have to pay for code 93970 for date of service August 22, 2022, billed under Claim A.
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, these services were 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 hospital medical records noted at the time of the appeal you were limited by left knee pain and fatigue. The records noted in hospital physical therapy you ambulated 15 feet with use of rolling walker and maximum assistance and were only able to participate in 33 minutes of therapy treatment. The Plan this does not meet the physical requirements for IRF care.
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 you were able 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. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that at the time of the appeal, SNF services were 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 noted that Maximus did not consider
that at the time of the appeal, you were limited by fatigue and weakness when out of bed and had not
yet progressed to ambulation attempts after 19 days of inpatient rehabilitation. At that point your care was
considered custodial which is not covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Based on the medical records provided, Medicare coverage criteria required for SNF care were not met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 based on the medical records; Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Maximus physician did not take into account that at the time of the appeal, the enrollee had a past medical history of depression, hypertension, diabetes mellitus, end-stage renal disease on hemodialysis, GERD, peripheral vascular disease, left foot cellulitis, and left foot gangrene.
The enrollee had elective left below knee amputation. The enrollee's functional status prior to coming to the hospital was requiring assistance for transferring. The enrollee required moderate assistance of one to two persons to transfer and maximum assistance to stand and walk on one foot. The therapy notes show the enrollee's ability to participate was limited by fatigue. At the time of the appeal the enrollee was not ready for a left lower extremity prosthesis. It was not a reasonable expectation that the enrollee would have the ability to participate in an IRF therapy level of care.
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. Based on the medical records, the enrollee did not meet this criterion. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on December 8, 2022.
You asked the Plan to waive the copayment for the CT scan. You say that you were in the office for 10 minutes for one test but was charged for two. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that they provided documentation to confirm the cost-sharing for this service. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Medicare-covered diagnostic CAT Scan at a freestanding provider.
You have been asked to pay a $50 copayment for the CT scan. This item/service falls within the Medicare-covered diagnostic CAT Scan at a freestanding provider 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 the CT scan provided on December 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Doxil for the enrollee.
You asked the Plan to pre-approve Doxil. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Doxil. Our Medical Director states that the requested use of Doxil with carboplatin and Mvasi (bevacizumab-awwb) is not Food and Drug Administration-approved as second-line or subsequent therapy for the enrollee's diagnosis. The requested use of Doxil with carboplatin and Mvasi (bevacizumab-awwb) as second-line or subsequent therapy for treatment of metastatic endometrial carcinoma (carniosarcoma with a component of a high-grade serous carcinoma) is not supported by one of the major drug compendia, the guidelines of the National Comprehensive Cancer Network or by clinical research that appears in a CMS-approved medical journal. Our
Medical Director found that the enrollee's condition does not meet criteria for coverage of Doxil. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Doxil have not been met. Therefore, we decided that the Plan does not have to pre-approve Doxil for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for hypoglossal nerve stimulation.
You asked the Plan to provide coverage for hypoglossal nerve stimulation. You say that at the time of the appeal, hypoglossal nerve stimulation was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial, even though the physician reviewer admitted the BMI criteria were not met. The Plan requested a reopen and stated that Maximus cannot make exceptions to the LCD.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules specifically that hypoglossal nerve stimulation (HNS) is reasonable and necessary when all of the required criteria are met. In particular the rule states the Body mass index (BMI) is less than 35 kg/m2. The rules also specifically state HNS is not reasonable or necessary when the BMI is 35 kg/m2 or greater. At the time of the appeal, the medical records clearly show the BMI was 35.98. Medicare rules for coverage of hypoglossal nerve stimulation were not met at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for hypoglossal nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63047 billed for date of service February 27, 
2023. 
 
You asked the Plan to pay for procedure code 63047. You say that the service is a separate procedure. The Plan 
denied your request. The Plan says payment for code 63047 is bundled into payment for code 22633. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 63047 is a column II code to column I code 22633. The medical 
records do not show that code 63047, with the -59 modifier, was a distinct procedural service. The records do 
not show that code 63047 was a different surgery, site, or separate incision site not ordinarily encountered with 
code 22633. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 63047 billed for date of service February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services for code 64721 for date of service 
May 23, 2023. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 64721. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
assistant surgeon services have not been met. Therefore, we decided that the Plan does not have to pay for 
assistant surgeon services for code 64721 for date of service May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device to be 
provided by an OON provider.  
 
You asked the Plan to pre-approve the motion exercise device. You say that you are the only supplier in the 
area that can provide this device. The Plan denied your request. The Plan says this item is available with in-
network providers. 
 
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 continuous passive motion exercise device to be provided by an OON provider.