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

 
We decided that the Plan does not have to pre-approve Kyprolis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Kyprolis is being requested in 
conjunction with plasma exchange and intravenous immune globulin (IVIG) infusion for transplant antibody-
mediated rejection after failing treatment with Rituxan. Kyprolis is not approved by the Food and Drug 
Administration (FDA) for the enrollee's diagnosis. The use is not supported by one of the major drug 
compendia or by clinical research appearing in a Medicare-approved medical journal. Kyprolis is therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kyprolis.
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 September 9, 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 Medicare coverage criteria were not met. Maximus overturned the Plans denial. After our original decision it was determined this decision was made in error.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for physical therapy (PT) services provided on September 9, 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." The case file also contains a note dated September 9, 2022. 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, 2022. It is reasonably expected that she should have been independent with a home exercise program by September 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 September 9, 2022.
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 July 29, 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 upheld the Plans denial. After the original decision was made it was determined the denial reason was not appropriate and the case was reopened.
Our Medical Director looked at the case file. At issue is coverage for physical therapy (PT) services provided on July 29, 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." The case file also contains a daily note dated July 29, 2022, 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 July 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 July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density measurement provided on February 16, 
2023. 
 
You asked the Plan to pay for the bone density measurement. You say that the enrollee was referred for this 
service. 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). The records show the referring provider is also out-of-network with the Plan. 
Therefore, we decided that the Plan does not have to pay for the bone density measurement provided on 
February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on March 08, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on March 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound and the biopsy provided on March 09, 2023. 
 
You asked the Plan to pay for the ultrasound and the biopsy. 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 the ultrasound and the 
biopsy provided on March 09, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on April 05, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $370 
copayment for outpatient surgery/for other outpatient procedures and services. 
 
You have been asked to pay a $370 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/for other outpatient procedures and services 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 an outpatient surgery provided on April 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided April 
7, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you have attached the 
supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says under 
Medicare guidelines, your request is not medically necessary because the records show the enrollee does not 
have psoriasis. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does 
not have to pay for the ultraviolet light therapy system (E0691) provided April 7, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 25, 2023, to  
March 15, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says this provider is a 
Licensed Marriage and Family Therapist (LMFT), which is not recognized as an independent provider type by 
Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist 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 Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 25, 2023, to 
March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain. 
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the record indicates the enrollee has 
cognitive impairment and is being treated for Alzheimer's disease. The record provided does not establish that 
the enrollee meets the diagnostic criteria of both AD and FTD. The elements of the coverage criteria are not 
satisfied. The requested service cannot be covered 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services rendered on September 12, 2022. 
 You asked the Plan to pay for the services. You say that the claim should not have been denied, and the claim 
should be reprocessed based on medical necessity. The Plan denied your request. The Plan says more 
information is needed to consider the charge. 
 
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 there is no documentation detailing the enrollee's history that prompted this testing. The criteria has 
not been 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services rendered on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCA 1/2 panel (81433) provided on March 6, 2023. 
 
You asked the Plan to pay for the BRCA 1/2 panel. You say that all genes in this assay have been shown to be 
associated with the tests billed. The Plan denied your request. The Plan says the requested genes in the BRCA 
1/2 panel (81433) are already included in the multi-cancer panel (81432), which is duplicative. 
 
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 81433 is hereditary breast cancer-related disorders (eg, 
hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion 
analysis panel, must include analyses for BRCA1, BRCA2, mutL homolog 1 (MLH1), mutS homolog 2 
(MSH2), and serine/threonine kinase 11 (STK11).  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rues to determine if the 
Plan was correct in denying the request to pay for the BRCA 1/2 panel. Our reviewer says that the billing of 
code 81433 is not supported. Our reviewer found that the laboratory report describes that the same genes were 
tested with a different method. Procedure code 81433 would not be billed separately from code 81432. 
 
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 BRCA 1/2 panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the BRCA 1/2 panel (81433) provided on March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group psychotherapy (90853) provided on September 6, 
2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that this should be covered. The Plan denied 
your request. The Plan says the provider in this case is not eligible to participate with Medicare. The Plan also 
says that payment cannot be made for services rendered by a provider that is not eligible to participate with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the group psychotherapy (90853) 
provided on September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (0329U). 
 
You asked the Plan to pre-approve genetic testing. You say that this could interfere with the enrollee's 
treatment and cause progression of her cancer. Specific testing is standard care for advanced solid tumor 
disease and this testing provides a more accurate calculation of selective therapies they can offer the enrollee. 
The Plan denied your request. The Plan says the requested testing 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. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, based on the diagnostic program, MolDX 
Technical Assessment, the requested test is not an approved test and therefore, is not covered by the Plan. 
Therefore, we decided that the Plan does not have to pre-approve genetic testing (0329U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
15, 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. 
 
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 February 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ear procedure provided on March 26, 2023. 
 
You asked the Plan to waive the copayment for ear procedure. You say that you say that you were told it would 
be $20 and now its $105. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $105 
copayment for emergency care. 
 
You have been asked to pay a $105 copayment for ear procedure. This item/service falls within the emergency 
care 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 ear procedure provided on 
March 26, 2023.