Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee is 
homebound. You say that the enrollee requires a provider that comes to them. You also say that the network 
provider does not offer this service as they are out of range. The Plan denied your request. The Plan says the 
requested DME can be provided within the enrollee's network. 
 
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 confirmed there is a 
network providers available in the enrollee's area who can provide the items at issue in this appeal. We found 
no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair and accessories to be provided by an out-of-network (OON) 
provider.
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, IRF care 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 IRF services.
The Maximus Physician Reviewer determined the requested services to be beneficial. The Plan requested a
reopen and argues the required Medicare criteria were not met. The Plan is correct in this case. The medical
record documentation does not support that the complexity of the nursing, medical and rehabilitation needs
required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper extremity CT scan (73200) provided on July 8, 
2022. 
 
You asked the Plan to pay for the upper extremity CT scan (73200). You say that the records support this 
procedure was performed by the provider and the claim denied as a duplicate in error. You say that the claim 
should be reviewed and reprocessed for reimbursement. The Plan denied your request. The Plan says this claim 
is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
  We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 20, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the upper extremity CT scan (73200) have not been 
met. Therefore, we decided that the Plan does not have to pay for the upper extremity CT scan (73200) 
provided on July 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not able to walk, sit up or care for yourself 
without assistance. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you would be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
July 19, 2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that the office staff advised they accepted 
your insurance. The Plan denied your request. The Plan says services performed by a licensed professional 
counselor are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy service have not been met. Specifically, services performed by a licensed 
professional counselor are not covered. Therefore, we decided that the Plan does not have to pay for the 
psychiatric diagnostic evaluation (90791) provided on July 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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. 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require daily skilled nursing or therapy services. The physician reviewer 
also found that you do not meet the severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility. 
 
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 pre-approve continued SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can receive the care they need in another setting. 
 
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 the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as home health. 
 
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 acute IRF admission and services.
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 that you were fully independent with all mobility at 
home but are now at high risk of falling and re-hospitalization. You say that you need close supervision and 
physical therapy to help gain your strength back. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs can be met at an alternate level of care. 
 
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 you are medically stable and do not require close supervision for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you can benefit from 
physical and occupational therapy, your needs can be safely provided in an alternate level of care such as a 
skilled nursing facility. 
 
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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory virus testing (code 87633) provided on April 
23, 2022. 
 
You asked the Plan to pay for the testing. You say that the testing was medically necessary. The Plan denied 
your request. The Plan says respiratory viral panels of 6 or more pathogens are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with greater than 5 respiratory pathogens 
performed in the outpatient setting are not considered medically reasonable and necessary.  
 
We looked at the file and Medicare rules. The respiratory virus testing you provided (code 87633) is a panel 
with between 12 and 25 pathogen targets. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory virus testing (code 87633) provided on April 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from acute rehab to optimize 
their level of functioning prior to returning home. You say that the enrollee has complex medical needs that 
require close daily care in an inpatient setting. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be provided safely in other settings. 
 
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 the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as a skilled nursing facility. 
 
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 acute IRF admission and services.
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 the enrollee fell down the stairs and has 
multiple intracranial hemorrhages. You say that the enrollee has spontaneous leg movements and is need of an 
LTACH. The Plan denied your request. The Plan says an LTACH admission in not medically necessary, and 
the enrollee's care needs can be provided in the current inpatient 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 the enrollee is more stable and should only require short-term additional acute care 
services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
   
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular cytogenic testing (codes 88271 and 88271) 
provided on April 25, 2022. 
 
You asked the Plan to pay for the testing. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the testing is not covered for the diagnoses listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular cytogenic testing may be covered only 
for limited diagnoses, as listed in the Medicare rules section.  
 
We looked at the file and Medicare rules. The record does not show the enrollee has one of the accepted 
diagnoses for coverage. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular cytogenic testing 
(codes 88271 and 88271) provided on April 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you still need more rehab. The Plan denied your 
request. The Plan says that the coverage criteria has no longer been met. 
 
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. 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing or therapy services. Your care needs 
can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy provided on June 1, 2022. 
 
You asked the Plan to pay for the medical nutrition therapy services. You say that this service meets medical 
necessity. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only 
for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy provided on June 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from February 11, 
2022 to March 7, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the home health care services. You say that upon the enrollee's admission, 
eligibility and benefits were checked, and no authorization was required. The Plan denied your request. The 
Plan says these services were rendered by a non-contracted provider. The Plan also says that a valid 
authorization is not on file for the services in question. 
 
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 home health care services provided from 
February 11, 2022 to March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 19, 2022. 
 
The enrollee asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The 
enrollee said that they were told by the insurance company that they would not responsible, and it was non-
emergency. The enrollee also said that this was an emergency trip, and is covered by Medicare. The Plan 
denied the enrollees request. The Plan says the provider has not submitted any clinical records to support the 
medical necessity of the services. 
 
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 non-emergency ambulance 
transportation and ground mileage have been met. Medical records were not provided with this case. The Plan 
requested this documentation multiple times, but it was not received. Without this information, we cannot 
determine if the services provided were medically necessary. Therefore, we decided that the Plan does not have 
to pay for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided on 
January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.
You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are 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 Evenity
(Romosozumab-aqqg). The Maximus Physician Reviewer noted that the enrollee had osteoporosis without
current pathological fracture but with a history of spinal compression fracture. It was reported that she tried
Fosamax for 2-3 years but continued to have fractures. Evenity was requested.
The Plan requested a reopen and argues the records are clear that the enrollee did not meet the required criteria.
The medical records show the enrollee was a then 92-year-old woman with osteoporosis and spinal
compression fractures. The enrollee took Fosamax for 2 - 3 years, starting in 2018, but this was discontinued as
she continued to get compression fractures. The Plan is correct in this case. The available documentation does
not support that Zoledronic acid or Prolia would likely be less effective, and/or would likely have adverse
effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity for the enrollee.