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

 
We decided that the Plan does not have to pre-approve genetic testing (81240). 
 
You asked the Plan to pre-approve genetic testing. You say that this service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the Factor V Leiden (FVL) variant in 
the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR gene which encodes the 
5,10-methylenetetrahydrofolate reductase enzyme is non-covered except for pregnant patients. 
 
We looked at the file and Medicare rules. This test is only covered for pregnant patients. Medical records 
provided do not show pregnancy. Based on this information, we decided that Medicare rules for coverage of 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing (81240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tissue Cypher test. 
 
You asked the Plan to pre-approve the requested services. You say that the test provides a score that correlates 
with the risk of cancer. The Plan denied your request. The Plan says the test does not indicate how the results 
determine the course of treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. The MolDX program requires tests to be reviewed to determine 
whether Medicare reasonable and necessary requirements are met. In this case, the requested test has not 
demonstrated clinical validity to fulfill the necessary criteria. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Tissue Cypher test.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81241). 
 
You asked the Plan to pre-approve genetic testing. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the requested test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the F2 gene (prothrombin coagulation factor II) 
and F5 gene (coagulation factor V) genetic tests are not considered to be clinically efficacious; therefore, 
testing is not medically necessary 
 
We looked at the file and Medicare rules. The requested test is considered not medically necessary by Medicare 
and is therefore non-covered. Based on this information, we decided that Medicare rules for coverage of 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing (81241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you must check your levels 3 times a day; therefore, 
the CGM is medically necessary. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is not using insulin and is not on medications that 
typically cause low blood sugars, nor are we told that they are having low blood sugars. Although a CGM 
might help the enrollee, coverage criteria are not met for the CGM at this time. If there is a reason why the 
enrollee is not able to use a meter, this information should be submitted and the case re-reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the respiratory assist device (E0470) and accessories 
(E0562, A7046, A7037, A7038, A7039, A7034, A7030, A7036). 
 
You asked the Plan to pre-approve the respiratory assist device and accessories . You say that the items are 
medically necessary. The Plan denied your request. The Plan says the documentation submitted indicates you 
are residing in a SNF. 
 
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 respiratory assist device and accessories  is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve the respiratory assist device (E0470) and 
accessories (E0562, A7046, A7037, A7038, A7039, A7034, A7030, A7036).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Synvisc One. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of left ankle pain. the enrollee has left ankle pain but minimal 
osteoarthritis. X- ray shows good joint space, no osteophytes, no bone lesions, no soft tissue calcifications. The 
enrollee has "excellent range of motion and strength and almost no arthritic changes on X-ray" per provider. 
The enrollee has tried and failed an ankle brace and cortisone injection which have not helped much. Synvisc-One is FDA-approved for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to 
respond adequately to conservative non-pharmacologic therapy and simple analgesics e.g., acetaminophen. The 
clinical value and effectiveness of Synvisc One for treatment of ankle pain due to osteoarthritis have not been 
demonstrated in the peer-reviewed literature. The requested use of Synvisc One is not FDA-approved for the 
enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 You asked the Plan to pre-approve Ocrevus. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Ocrevus. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has Multiple Sclerosis. The documentation does not support that the enrollee has tried and 
failed Glatopa (preferred) or Gilenya. The documentation does not support that Glatopa (preferred) or Gilenya 
would likely be less effective and/or likely have adverse effects for the 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 Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 16, 2023, billed 
with evaluation and management (EM) code 99222. 
 
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 was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the POS code is generally used to reflect the 
actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was inappropriately billed with 
POS 21 as the enrollee was registered outpatient observation on this date of service. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 16, 2023, billed with evaluation 
and management (EM) code 99222.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lingraphica Touch Talk Plus device to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the Lingraphica Touch Talk Plus device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there are in-network providers available for this 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 
the Lingraphica Touch Talk Plus device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve a Dexcom G7 sensor. You say that due to your medical issues, the Dexcom 
G7 sensor is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare 
criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Dexcom G7 sensor. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found that you are not using insulin and 
blood sugar control is excellent in March 2023. We are not told of low blood sugar but the medication you are 
on typically do not cause low blood sugars. Although a CGM may help you, coverage criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Dexcom G7 sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G7 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0266). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0266).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service September 30, 
2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 22, 2022. The NOA was not received by the Plan until February 
17, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 7, 2022, billed 
with evaluation and management (EM) code 99233-FS. 
 
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 documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, no medical records for the date of service in question have been provided for review. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on September 7, 
2022, billed with evaluation and management (EM) code 99233-FS.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Polivy (polatuzumab vedotin). 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 
the medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of relapsed/refractory nodal marginal zone lymphoma. The FDA has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. 
 
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 Polivy (polatuzumab vedotin).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from November 22, 2022, to 
November 26, 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 that the DRG was updated. 
 
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 case file appears to indicate that the plan had medical records in order to 
come to their denial decision. However, the plan did not provide these medical records to MAXIMUS for 
review. Therefore, we decided that the Plan has to pay for inpatient hospital services rendered from November 
22, 2022, to November 26, 2022.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require an IRF admission to regain your 
previous independence. The Plan denied your request. The Plan says that the IRF services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that your condition is, in fact, complex and fragile, and there is sufficient reason to expect that you will 
participate in and benefit from IRF services. A lower level of care is inadequate for the pace and quality of care 
you require. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0159, G0160, G0299, Q5001) 
provided on February 26, 2022, to March 27, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 27, 2022. The NOA was not received by the Plan until June 1, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0159, 
G0160, G0299, Q5001) provided on February 26, 2022, to March 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission. 
 
You asked the Plan to pre-approve an inpatient psychiatric admission. You say that the enrollee needed an 
inpatient level of hospitalization for aggressive medication management changes and close observation. The 
Plan denied your request. The Plan says this request is not medically necessary because the records received 
show the enrollee was not a threat to themself or others, and they were able to care for themself. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an inpatient psychiatric admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for inpatient psychiatric care. Our physician 
reviewer found it is not expected this enrollee will improve in a reasonable period of time as they did not have 
dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any 
behavioral issues. The enrollee is noted to be cooperative and compliant with treatment while not showing any 
aggressive behaviors. Our reviewer also found that it does not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient psychiatric admission.