Persius/hicric huggingface dataset:
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 is medically complex to 
receive a lower level of care. You say that the enrollee would need daily physician visits and extensive 
rehabilitative therapies to regain strength. The Plan denied your request. The Plan says an LTACH admission is 
not medically necessary, and the enrollee can receive the care they need in the current hospital 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 somewhat unstable and should only require short-term additional acute 
care services that can safely be administered at the current facility until their more stable to transfer. 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the drugs (J0490) provided on November 8, 2021. 
 
You asked the Plan to pre-approve the drugs. The Plan denied your request. The Plan says that these services 
were paid to another provider on the same date of service. 
 
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 Plan has not provided documentation showing that the services (J0490) 
were paid on another claim to another provider for this date of service. Without supporting documentation, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pre-approve the drugs (J0490) 
provided on November 8, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 24, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the supplies are medically necessary. The 
Plan denied your request. The Plan says you do not meet coverage criteria for the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 20, 2022 to  
May 22, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission, the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 20, 2022 to May 22, 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: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
February 14, 2022, to February 24, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 14, 2022, to  
February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the denial and have 
submitted additional clinical information for review. The Plan denied your request. The Plan says the enrollee 
does not meet coverage criteria for the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided the Plan has to pay for inpatient care provided to the enrollee from January 1, 2022 to January 19, 2022.
You asked the Plan to pay for acute inpatient hospital care from January 1, 2022, to January 19, 2022. You say that the remainder of this claim should be paid as the enrollee was admitted from December 22, 2021, to January 19, 2022. The Plan denied your request. The Plan says that the enrollee's contract with the Plan ended on December 31, 2021. Maximus upheld the Plans denial. The Plan requested a reopen again stating the enrollee termed with the Plan on December 31, 2021.
Our decision in this case is unchanged. The Plan must follow Medicare rules. The rules say if the enrollee's plan coverage changes during an inpatient stay, the full payment of the inpatient admission is the responsibility of the plan the enrollee was a member of on the date the admission began. The medical records show the inpatient admission for this enrollee began on December 22, 2021 and ended on January 19, 2022. Therefore, the Plan is responsible for payment of the entire stay from January 1, 2022, to January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for dates of service October 29, 2021, and 
November 1, 2021. 
 
You asked the Plan to pay for code 99291. You say that you provided medical records to support payment. The 
Plan denied your request. The Plan says the records do not support the billing of this code. 
 
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 99291 is evaluation and management of the critically ill 
or critically injured patient, first 30-74 minutes).  Code 99291 is a timed code, meaning that the total time spent 
on this service must be documented in the medical record.  On the dates of service in question, the number of 
minutes spent with the patient was not documented in the medical record, so the billing of code 99291 cannot 
be supported. Therefore, we decided that the Plan does not have to pay for code 99291 billed for dates of 
service October 29, 2021, and November 1, 2021.
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. The Plan denied your request. The Plan says the service requested 
is not supported based on the records we received. 
 
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 on review of the records the enrollee does not meet the criteria for an IRF admission. 
The enrollee is medically improving but not totally stable, needing acute hospital care.  
 While the enrollee would benefit from speech, physical and occupational therapy, her rehabilitation needs can 
be safely provided in an alternate and low intensity setting such as in a skilled nursing facility when more 
stable medically. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
system and sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM system and sensor. You say that you need the 
requested sensor. The Plan denied your request. The Plan says you are not receiving insulin shots or using an 
insulin pump, so the CGM is not medically necessary and not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM system and sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitor (CGM) system and sensor.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat right knee injection. 
 
You asked the Plan to pre-approve the repeat injection. You say that the requested injection is necessary for the 
enrollee. The Plan denied your request. The Plan says that the requested injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the repeat injection. Our reviewer says 
that the requested injection is considered medically reasonable and necessary in this case. Our physician 
reviewer found the coverage guidelines for steroid injection into the knee is no more than one injection every 
three months with a maximum of 4 per year. The reviewer found that it has been more than 3 months since the 
previous injection. Therefore, the reviewer found that a repeat injection is medically reasonable and 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 repeat injection have been met. Therefore, we decided that the Plan has to 
pre-approve a repeat right knee injection.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed 
Clinical Social Worker (LCSW) on June 7, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says there is no evidence that the provided 
attempted to consult with the patient's primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services provided by a Licensed Clinical Social Worker (LCSW) on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership purchased on December 12, 2021.
You asked the Plan to pay for the gym membership. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for the gym membership purchased in this case.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits for up to a combined total of $240 per year for approved services. The Plan has provided documentation confirming you exhausted your $240 wellness benefit on January 12, 2021. Therefore, we decided that the Plan does not have to pay for the gym membership purchased on December 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the provider needs to 
bill Original Medicare as this is covered under the hospice benefit. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided 
on February 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 99292 billed for date of service 
June 15, 2022. 
 
You asked the Plan to pay for procedure code 99292. You say that these services were denied in error. The 
Plan denied your request. The Plan says payment for code 99292 is bundled into payment for code 99152. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99292 
is a column II code to column I code 99152. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for two units of procedure code 99292 billed for date of service June 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on June 15, 2022. 
 
You asked the Plan to pay for chiropractic treatment. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic treatment provided on June 15, 2022.