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

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your request. The Plan says that that Keytruda as a single agent is not indicated by the National Comprehensive Cancer Network (NCCN) guidelines.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda. Our Medical Director states that there is insufficient support in the medical literature for the use of Keytruda as monotherapy in the setting of recurrent adenocarcinoma of the lung with PDL1 70%, and EGFR EXON 20 mutation. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of Keytruda.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services (97110 x 10). 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee needs these services. The 
Plan denied your request. The Plan says the requested PT services are not medically necessary.   
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to provide treatment safely and effectively, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. The reviewer also found that the enrollee has had extensive prior therapy and has 
had instruction in a home exercise program. Therefore, the reviewer found that the requested PT services are 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services (97110 x 10).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310), universal serial bus (USB) charger (K0108), and direct back rest 
frame (K0108). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor, USB charger, and direct back rest frame. You say that you would like the necessary 
electronics for the power wheelchair to be approved. The Plan denied your request. The Plan says although a 
single power feature is requested for this wheelchair, there is not a medical need to control this power option 
through the joystick. The Plan says the requested K0108 USB charger does not serve a medical purpose, is not 
medically necessary and cannot be approved. The Plan also says the back cushion mount hardware is 
unbundled from the approved back cushion, and cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 electronic connection between 
wheelchair controller and one power seating system motor, USB charger, and direct back rest frame. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records document that the enrollee has 3 to 5, out of 5 bilateral upper 
extremity strength and is independent with feeding, dressing, and bathing thus indicating they have adequate 
upper extremity strength and function to operate the wheelchair's power options with their own switches. Our 
reviewer found that the requested USB charger is statutorily non-covered as it serves no primary medical 
purpose. Our physician reviewer also found that the direct back rest frame (K0108) is unbundled from the 
approved back cushion and is not covered separately. 
 
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 electronic connection between wheelchair controller and one power seating 
system motor, USB charger, and direct back rest frame have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and one power seating 
system motor (E2310), universal serial bus (USB) charger (K0108), and direct back rest frame (K0108).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.

You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The medical records provided show that at the time of the appeal, the enrollee did not require daily skilled nursing or daily skilled therapy services at an inpatient SNF level of care. The enrollee basically had custodial needs, which are not covered in a SNF setting. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pay for the periodic oral evaluation (D0120) and the dental cleaning (D1110) provided on October 12, 2022.

You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan.  The Plan denied your request. The Plan says this benefit was exhausted on April 7, 2022. Maximus overturned the Plans denial for insufficient information in the case file to show this service was already covered. The Plan requested a reopen and submitted the required documentation. 

The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, your dental records show this benefit was exhausted April 7, 2022. Therefore, we decided that the Plan does not have to pay for pay for the periodic oral evaluation (D0120) and the dental cleaning (D1110) provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 
10, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services and are appealing the denial. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.

You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF 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. 

Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued SNF services. The medical records show you have a medical history that included multiple sclerosis, hypertension, and age-related osteoporosis. You suffered a displaced fracture of her right hip on February 18, 2023. Surgery was performed on February 24, 2023.  The Physical Therapy Discharge Summary dated March 7, 2023, states that the reason for discharge was "Highest Practical Level Achieved', and the destination was a long-term care setting. The Occupational Therapy Discharge Summary dated March 13, 2023, states that the reason for discharge was "Exhausted benefits and, patient declines treatment', and the destination was a long-term care setting. It was noted you were to reside in the long-term care facility until weight-bearing on the hip progressed. The Plan is correct in this case. There are no required skilled nursing services identified at the time of the appeal The documentation does not sufficiently support that you required continued skilled therapy services on a "daily basis" on an inpatient basis, in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service January 23, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service January 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on March 9, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is a non-Medicare approved/certified 
freestanding emergency facility.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0650, and related supplies billed with codes 97760, E0673, and E0666 billed for dates of service September 
28, 2021, to October 21, 2021. 
 
You asked the Plan to pay for the PCD and related supplies. You say that this item was medically necessary to 
prevent the patient from developing lymphedema and to reduce post-surgical complications. The Plan denied 
your request. The Plan says the billed PCD and related supplies are not covered for the patient's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0650 or E0651 is covered for 
patients with chronic and severe lymphedema. 
 
In this case, you billed the PCD at issue with code E0650.  Under Medicare rules, this specific PCD is only 
covered for patients with chronic and severe lymphedema.  According to the documentation submitted, this 
device was not provided for chronic or severe lymphedema.  Rather, this item was provided to prevent deep vein thrombosis following knee surgery.  This PCD is not covered for this indication.  As a result, none of the 
associated accessories would be covered either. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PCD and related supplies have not been met. Therefore, we decided that the Plan does not have 
to pay for the pneumatic compression device (PCD) billed with code E0650, and related supplies billed with 
codes 97760, E0673, and E0666 billed for dates of service September 28, 2021, to October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee requires this machine due to 
COPD and severe hypercapnia. You say that bilevel positive airway pressure (BiPAP) will be ineffective due to 
the inability to provide longer expiratory time to decrease carbon dioxide (CO2) retention.  The Plan denied 
your request. The Plan says the requested ventilator is not covered because it will be set in a BiPAP mode that 
could be provided with a BiPAP device.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met.  Our physician reviewer found a home ventilator is not 
medically necessary.  The enrollee was recently hospitalized with an acute exacerbation of COPD and 
community acquired pneumonia.  There is also severe obesity.  There are no pulmonary function tests to assess 
the severity of the COPD.  The enrollee is described as having hypercarbic respiratory failure, but no blood gas 
results are provided, and there is no arterial blood gas (ABG) done while stable to document chronic CO2 
retention.  If that is present, the enrollee may benefit from BiPAP with average volume assured pressure 
support (AVAPS) during sleep. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311), a power seat elevation feature (E2300) and mobile device charger (K0108).

You asked the Plan to pre-approve an expandable controller, harness, electronic connection, a power seat elevation feature and mobile device charger. You say that these items are medically necessary. The Plan denied your request. The Plan says that the set lift and mobile charger device do not have a medical purpose. The Plan also says that the upgraded electronics are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller, harness and electronic connection. Our Medical Director states that the clinical documentation in the case file does not support that an electronic connection (E2311), expandable controller (E2377), and harness (E2313) were medically reasonable and necessary for the enrollee in this case. The upper limb strength and function appear to be adequate for the enrollee to control the power options using their own switches which are included in the allowance of these power options. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an expandable controller, harness and electronic connection.

We looked at this physician's review, the file, and Medicare rules. The power seat elevation feature and mobile device charger do not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness, electronic connection, a power seat elevation feature and mobile device charger have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection (E2311), a power seat elevation feature (E2300) and mobile device charger (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service July 7, 2022.

You asked the Plan to pay for this service. You say that this claim should be paid.  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 provided additional information. The Plan noted that the unlisted code J3490 for NDC 00409115902 was properly denied, because Bupivacaine is a local anesthetic agent that cannot be separately reimbursed from the injection procedure 27096 that was billed on the same claim. Per Medicare Claims Processing Manual Chapter 12, Section 30.5.C - Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy): A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable:
1. Use of local anesthesia;
2. IV start;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion; and
5. Standard tubing, syringes and supplies.
Payment for the above is included in the payment for the chemotherapy administration or
nonchemotherapy injection and infusion service.

Based on these Medicare guidelines, the Plan has correctly denied J3490 for payment as payment for the
local anesthetic is included in the payment for the chemotherapy administration or nonchemotherapy
injection and infusion service

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 code. In this case, code J3490 cannot be separately billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed to the enrollee for date of service July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and drug services rendered on July 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service 
 
We looked at the file and Medicare rules. Billed procedure codes 31627, 88172, 88173, 88305, 88341, 88342, 
88360, J1100, J2405, J2704, J3010 and J7999 have an OPPS status indicator of N, meaning payment for these 
codes is included in the facility payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory and drug services rendered on July 22, 2022.