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

 
We decided that the Plan does not have to pre-approve hydration intravenous (IV) infusion (96360), saline 
solution (J7040), multiple vitamins (A9153), and Parenteral nutrition (B4216). 
 
You asked the Plan to pre-approve the infusion services. You say that the enrollee needs these services. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 pre-approve the infusion services. Our reviewer says 
that the requested infusion services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation provided for review does not indicate the enrollee had clinical 
dehydration with any significant electrolyte disturbance that would require IV hydration over oral hydration. 
Therefore, the reviewer found that the requested IV hydration is 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 infusion services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hydration intravenous (IV) infusion (96360), saline solution (J7040), multiple 
vitamins (A9153), and Parenteral nutrition (B4216).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided May 12, 2022. 
 You asked the Plan to pay for Guardant360 testing. You say that this testing was required to determine optimal 
treatment options for the enrollee. The Plan denied your request. The Plan says there is insufficient reliable 
evidence in the form of high-quality peer-reviewed medical literature to establish the safety and efficacy or 
effects on health care outcomes. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must meet the criteria listed in the 
Medicare Rules section of this letter in order for Guardant360 CDx testing to be 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 Guardant360 testing. Our reviewer says that 
this testing is not medically reasonable and necessary. Our physician reviewer found that the records do not 
show that the enrollee has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid 
tumor that did not originate from the central nervous system. The enrollee has not been previously tested with 
Guardant360 for the same genetic content. The records do not show that the enrollee is untreated for the cancer 
being tested or is not responding to treatment. It is unclear if the enrollee decided to seek further cancer 
treatment and is a candidate for further treatment with a drug that is FDA approved or has a NCCN or NCCN 
2A recommendation for the enrollee's cancer. It is not known if tissue-based CGP infeasible or specifically in 
NSLC Tissue-based CGP has shown no actionable mutations. Therefore, the enrollee does not meet all criteria 
for coverage of the requested testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant360 testing provided May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; single level (64490) and injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical 
or thoracic; second level (64491). 
 You asked the Plan to pre-approve facet injections. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says medical necessity for facet injections 
has not been met per the LCD. The clinical documentation received does not describe at least 3 months of 
cervical or thoracic pain with functional impairment. 
 
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 pre-approve injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the imaging shows both multi-level facet arthropathy and degenerative disc disease. She has 
started physical therapy. Per the LCD criteria, pain must be present for 3 months and treated with conservative 
therapy during that time. This time period has not elapsed yet, therefore, the enrollee does not meet criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level (64490) and 
injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (64491).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for surgical repair of a hip fracture after a fall. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy 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 will 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service July 20, 
2022. 
 
You asked the Plan to pay for procedure code 93010. The Plan denied your request. The Plan says payment for 
code 93010 is bundled into payment for code 93000. 
 
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 93010 
is a column II code to column I code 93000. 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 procedure code 93010 billed for date of service July 20, 2022.  
 
We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We 
cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan 
for further review. We are only permitted to make a decision based on the claim information reviewed by the 
Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after December 10, 
2022. 
 
You asked the Plan to pre-approve SNF care after December 10, 2022. You say that the continued admission to 
a SNF is medically necessary. The Plan denied your request. The Plan says that the continued admission to a 
SNF is not medically necessary. 
 
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 after December 10, 2022. Our 
reviewer says that the requested SNF care is considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the documentation shows that the enrollee continues to require 
clinical assessment by skilled nursing as there have been multiple medications changes. Clinical documentation 
shows that the enrollee still requires skilled therapy with complex functional impairments thus continued daily 
skilled services in a skilled nursing facility is 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 SNF care after December 10, 2022, have been met. The Plan must continue 
coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper 
notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has 
to pre-approve continued skilled nursing facility (SNF) care after December 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 6, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have two or more 
doctors' appointments this year. You have already experienced amputation and would not like to have another. 
You do not think its a good idea to wait until next year before seeing your specialist. The Plan denied your 
request. The Plan says you have exhausted your benefit maximum of 50 one-way non emergent transportation 
trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus HRD test provided on May 25, 2022. 
 
You asked the Plan to pay for the Tempus HRD test. You say that this test was medically necessary. The Plan 
denied your request. The Plan says the date-of-service and place-of-service were submitted incorrectly for this 
claim. Additionally, this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus testing is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus HRD test have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus HRD test provided on May 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 23, 2022, to 
April 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with th edenial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 23, 2022. The NOA was not received by the Plan until January 22, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 23, 2022, to April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says transfer to an LTACH is not medically necessary. 
The Plan says that the enrollee can safely receive the care needed 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 currently undergoing treatment at an acute care hospital (ACH) for 
pneumonia in the setting of a recent thalamic stroke.  The enrollee previously received a tracheotomy and 
feeding tube.  The enrollees long-term prognosis is noted to be poor.  There is no evidence that the enrollee 
requires services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level 
of care, there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current 
ACH until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower 
level of care for any ongoing long term care needs.  
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the records provided support the need for the 
requested device. The Plan denied your request. The Plan says the requested ventilator would be set in 
intelligent volume-assured pressure support (IVAPS) mode that could be delivered by bi-level positive airway 
pressure (BiPAP), and therefore is not covered. 
 
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 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 exacerbation of chronic obstructive pulmonary disease 
(COPD) and pneumonia, and arterial blood gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure. The enrollee improved on BiPAP.  There are no PFTs to assess severity of the COPD, and 
no ABG done while stable to document chronic CO2 retention.  If the patient does have chronic CO2 retention, 
may benefit from BiPAP with AVAPS during sleep. But Medicare does not cover a home ventilator when used 
as BiPAP.  The denial is upheld.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital service provided on 
January 27, 2022, to February 8, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital service. You say that you rather your Plan is 
responsible for this. 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 20% 
coinsurance for inpatient hospital care. The allowed amount of this inpatient hospital care service total 
$10,295.88, resulting in a total coinsurance amount of $2,059.17. You are responsible for $1,866.40 which is 
less than the $2,059.17.  
 
You have been asked to pay 20% coinsurance for inpatient hospital service. This item/service falls within the 
inpatient hospital 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 coinsurance for inpatient 
hospital service provided on January 27, 2022, to February 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve 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.
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. The patient must need and be expected to
actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive
rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per
week.
Based on the medical records provided, the enrollee did not meet these criteria. Medicare rules for coverage of
IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient
rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from skilled nursing 
services due to their medical complexity. The Plan denied your request. The Plan says an SNF admission is not 
medically necessary. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only 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 SNF care.